The optimal timing for intervention in patients with ST-segment elevation myocardial infarction and multivessel
Yi Chen1, Meng Li1, Yanqing Wu1
1The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China.
Insights
For ST-elevation myocardial infarction (STEMI) patients with multivessel coronary disease (MVD), staged percutaneous coronary intervention (PCI) significantly reduces myocardial infarction and revascularization risk compared to immediate PCI. Observational data also suggest potential mortality benefits with staged PCI.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiovascular Research
Background:
- Optimal timing for nonculprit vascular reconstruction in ST-segment elevation myocardial infarction (STEMI) with multivessel coronary disease (MVD) remains debated.
- Percutaneous coronary intervention (PCI) strategies for MVD in STEMI patients require further clarification.
Purpose of the Study:
- To determine the optimal timing for percutaneous coronary intervention (PCI) in patients experiencing STEMI with multivessel coronary disease (MVD).
- To compare immediate versus staged multivessel PCI in STEMI patients.
Main Methods:
- A meta-analysis of randomized trials and prospective observational studies was conducted.
- Databases searched included PubMed/Medline, EMBASE, Cochrane Library, and ClinicalTrials.gov up to January 1, 2024.
- Primary outcomes included all-cause death, cardiovascular death, myocardial infarction, and unplanned revascularization.
Main Results:
- Staged PCI significantly reduced myocardial infarction (MI) and unplanned revascularization compared to immediate PCI in randomized trials.
- No significant differences in mortality were observed between immediate and staged PCI in randomized trials.
- Prospective observational studies indicated potential reductions in all-cause and cardiovascular mortality with staged PCI.
Conclusions:
- Staged multivessel PCI appears to be a superior strategy for reducing MI and revascularization in STEMI patients with MVD, based on randomized trial data.
- While randomized trials showed no mortality benefit, observational data suggest staged PCI may improve survival.
- Further investigation into the mortality benefits of staged PCI in STEMI with MVD is warranted.
Purpose:
The optimal timing for nonculprit vascular reconstruction surgery in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary disease (MVD) is still controversial. Our aim was to explore the optimal intervention time for percutaneous coronary intervention (PCI) in STEMI patients who underwent MVD.
Methods:
The PubMed/Medline, EMBASE, Cochrane Library, and ClinicalTrials.gov databases were searched from inception to January 1, 2024 for clinical studies comparing immediate multivessel PCI and staged multivessel PCI in patients with STEMI. The primary outcomes were death from any cause, cardiovascular death, noncardiac death, myocardial infarction (MI) and unplanned ischemia-driven revascularization. The secondary outcomes were ischemic stroke, stent thrombosis, renal dysfunction and major bleeding. The risk ratios (RRs) and odds ratios (ORs) were calculated with fixed-effects models and random-effects models, and 95% confidence intervals (CIs) were calculated.
Findings:
Five randomized trials with 2,782 patients and six prospective observational studies with 3,131 patients were selected for inclusion in this meta-analysis. The staged PCI group had significantly lower pooled RRs for myocardial infarction (0.43, 95% CI = 0.27-0.67; P = 0.0002) and unplanned ischemia-driven revascularization (0.57, 95% CI = 0.41-0.78; P = 0.0004). There were no significant differences in any cause of death, cardiovascular cause of death, or noncardiac cause of death. However, the results of prospective observational studies in the real world indicated that the staged PCI group had significantly lower pooled ORs for all-cause mortality (2.30, 95% CI = 1.22-4.34; P = 0.01), cardiovascular death (2.29, 95% CI = 1.10-4.77; P = 0.03), and noncardiovascular death (3.46, 95% CI = 1.40-8.56; P = 0.007).
Implications:
According to our randomized trial analysis, staged multivessel PCI significantly reduces the risk of myocardial infarction and unplanned ischemia-driven revascularization compared to immediate multivessel PCI. There was no significant difference between the two groups in terms of all-cause mortality, cardiovascular mortality, or noncardiovascular mortality risk. However, prospective non-randomized studies suggest there might be a benefit in mortality in the staged PCI group. Therefore, staged multivessel PCI may be the optimal PCI strategy for STEMI patients with MVD.
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