Multivessel Revascularization in STEMI PCI Patients

Study Questions:

What is the effectiveness of the different revascularization strategies in ST-segment elevation myocardial infarction (STEMI) patients with multivessel coronary artery disease undergoing primary percutaneous coronary intervention (PCI)?

Methods:

The investigators included trials that randomized STEMI patients with multivessel disease to any combination of the four different revascularization strategies (i.e., complete revascularization at the index procedure, staged procedure during the hospitalization, staged procedure after discharge, or culprit-only revascularization). Random-effect risk ratios (RRs) were conducted. Network meta-analysis was constructed using mixed treatment comparison models, and the four revascularization strategies were compared. The network meta-analysis was performed using a random-effects model in order to account for the heterogeneity between the trials.

Results:

Ten trials with 2,285 patients were included. In the pairwise meta-analysis, complete revascularization (i.e., at the index procedure or as a staged procedure) was associated with a lower risk of major adverse cardiac events (MACE) (RR, 0.57; 95% confidence interval [CI], 0.42-0.77), due to lower risk of urgent revascularization (RR, 0.44; 95% CI, 0.30-0.66). The risk of all-cause mortality (RR, 0.76; 95% CI, 0.52-1.12), and spontaneous reinfarction (RR, 0.54; 95% CI, 0.23-1.27) was similar. The reduction in the risk of MACE was observed irrespective of the timing of nonculprit artery revascularization in the mixed treatment model.

Conclusions:

The authors concluded that complete revascularization at the index procedure or as a staged procedure was associated with a reduction of MACE due to reduction in urgent revascularization with no difference between the three strategies.

Perspective:

This study reports that a complete revascularization strategy at the index procedure or as a staged procedure whether during the hospitalization or after discharge was associated with a reduction in the risk of MACE. Lower MACE was driven primarily by a reduction in the risk of urgent revascularization. Additional trials are needed to determine the impact of complete revascularization on hard endpoints such as the risk of all-cause mortality and spontaneous reinfarction. Two ongoing prospective trials, COMPARE ACUTE and COMPLETE, will provide additional insight on this important clinical issue.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and ACS, Interventions and Coronary Artery Disease

Keywords: Acute Coronary Syndrome, Coronary Artery Disease, Myocardial Infarction, Myocardial Revascularization, Patient Discharge, Percutaneous Coronary Intervention, Risk, Secondary Prevention


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