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Immediate Versus Staged Complete Revascularization for Patients With ST-Segment-Elevation Myocardial Infarction and
Ayman Elbadawi1,2, Mohamed Hamed3, Mohamed Gad4
1Division of Cardiology Christus Good Shepherd Medical Center Longview TX USA.
Insights
For ST-segment-elevation myocardial infarction patients with multivessel disease, immediate nonculprit PCI shows similar outcomes to staged PCI. However, out-of-hospital staged PCI increases major adverse cardiac events, primarily due to repeat revascularization needs.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Outcomes of complete revascularization strategies for ST-elevation myocardial infarction (STEMI) with multivessel disease are not well-defined.
- Immediate, in-hospital staged, and out-of-hospital staged revascularization are potential approaches.
Purpose of the Study:
- To compare the clinical outcomes of immediate, in-hospital staged, and out-of-hospital staged complete revascularization in STEMI patients with multivessel disease.
Main Methods:
- A systematic review and meta-analysis of randomized controlled trials was conducted.
- Searched MEDLINE, SCOPUS, and Cochrane databases through August 2023.
- Included 9 trials with 4270 patients, focusing on major adverse cardiac events (MACEs).
Main Results:
- Immediate nonculprit PCI and staged nonculprit PCI (in-hospital) demonstrated similar MACE rates.
- Out-of-hospital staged nonculprit PCI was associated with significantly higher MACEs compared to immediate PCI.
- Staged out-of-hospital PCI also showed increased odds of ischemia-driven repeat revascularization.
Conclusions:
- Immediate nonculprit PCI is a safe and effective strategy for STEMI patients with multivessel disease.
- Staged in-hospital nonculprit PCI offers comparable outcomes to immediate PCI.
- Staged out-of-hospital nonculprit PCI should be approached with caution due to increased MACE risk.
Background:
The comparative outcomes with immediate, staged in-hospital, and staged out-of-hospital complete revascularization for patients with ST-segment-elevation myocardial infarction and multivessel disease remain unclear.
Methods And Results:
An electronic search of MEDLINE, SCOPUS, and Cochrane databases was performed through August 2023 for randomized trials evaluating immediate, staged in-hospital, and staged out-of-hospital complete revascularization for patients with ST-segment-elevation myocardial infarction and multivessel disease. The primary outcome was major adverse cardiac events (MACEs). The final analysis included 9 trials with 4270 patients. The weighted follow-up duration was 13.8 months. On pairwise meta-analysis, there were no statistically significant differences between immediate versus staged nonculprit percutaneous coronary intervention (PCI) in MACEs (odds ratio, 0.79 [95% CI, 0.54-1.16]). Network meta-analysis showed that there was no statistically significant difference in MACEs with staged in-hospital nonculprit PCI (odds ratio, 1.29-[95% CI, 0.91-1.82]) compared with immediate nonculprit PCI, while there were higher odds of MACEs with out-of-hospital nonculprit PCI (odds ratio, 1.67-[95% CI, 1.21-2.30]) compared with immediate nonculprit PCI. Compared with immediate nonculprit PCI, there were higher odds of ischemia-driven repeat revascularization with staged out-of-hospital nonculprit PCI (odds ratio, 2.26-[95% CI, 1.37-3.72]), but not with in-hospital staged nonculprit PCI. There were no significant differences for the other outcomes among the 3 strategies.
Conclusions:
Among patients with ST-segment-elevation myocardial infarction with multivessel disease, an immediate nonculprit PCI approach was associated with similar clinical outcomes to the staged nonculprit PCI approach. The staged out-of-hospital nonculprit PCI approach was associated with a higher incidence of MACEs compared with the other strategies, which was driven by higher risk for ischemia-driven repeat revascularization.
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