Complete vs. Culprit Artery Revascularization in STEMI With Multivessel Disease

Study Questions:

What are the outcomes with complete multivessel percutaneous coronary intervention (MV-PCI) versus noncomplete MV-PCI for ST-segment elevation myocardial infarction (STEMI) and MV coronary artery disease?

Methods:

The investigators performed a meta-analysis of randomized controlled trials (RCTs) comparing complete MV-PCI with noncomplete MV-PCI in STEMI and MV disease. Complete MV-PCI was defined as revascularization to noninfarct-related artery lesions during index procedure, noncomplete MV-PCI–encompassed culprit-only revascularization, and staged approaches. Multiple databases and congress proceedings from major cardiovascular societies’ meetings were screened for relevant studies. The primary endpoint was the composite of major adverse cardiac events (MACE) typically defined as death, recurrent MI, and repeat revascularization. Secondary endpoints were cardiovascular mortality, recurrent MI, and repeat revascularization. Outcomes were analyzed at longest available follow-up, with differences accounted for with adjusted models by person-years.

Results:

Seven RCTs (n = 1,303) were included. The median follow-up was 12 months. Complete MV-PCI reduced the odds of MACE compared with noncomplete MV-PCI (odds ratio [95% confidence intervals], 0.59 [0.36-0.97]; p = 0.04), driven by a reduction in recurrent MI (0.48 [0.27-0.85]; p = 0.01) and repeat revascularization (0.51 [0.31-0.84]; p = 0.008). Complete MV-PCI was associated with a nonsignificant trend towards reduced cardiovascular mortality (0.54 [0.26-1.10]; p = 0.09) as well. In a sensitivity analysis, none of the baseline clinical variables significantly influenced overall estimates.

Conclusions:

The authors concluded that in STEMI and MV disease, complete MV-PCI as compared with a noncomplete strategy reduces MACE by 41%, driven by a 52% reduction in recurrent MI and 49% reduction in repeat revascularization.

Perspective:

This meta-analysis reported that complete MV-PCI as compared with noncomplete MV-PCI is associated with a significant reduction of the composite primary endpoint of MACE driven by significantly reduced rates of repeat revascularization and recurrent MI, and is associated with numerical reduction of the odds of cardiovascular mortality. While these results would suggest a relook at current guidelines regarding primary PCI in STEMI and MV disease, additional prospective, adequately powered randomized studies are indicated to definitively assess risks versus benefits of culprit versus MV PCI among hemodynamically stable patients with STEMI.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Interventions and ACS, Interventions and Coronary Artery Disease

Keywords: Acute Coronary Syndrome, Coronary Artery Disease, Myocardial Infarction, Percutaneous Coronary Intervention, Risk


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