Complete Revascularization During PCI for Multivessel STEMI

Study Questions:

What are the outcomes with complete revascularization versus a culprit-only strategy in patients presenting with ST-segment elevation myocardial infarction (STEMI) and multivessel disease?

Methods:

The investigators identified randomized trials comparing complete revascularization with culprit-only revascularization in patients with STEMI without cardiogenic shock by a systematic search of published research. Random-effects meta-analysis was performed, comparing clinical outcomes in the two groups.

Results:

Eleven trials were identified, including a total of 3,561 patients. Compared with a culprit-only strategy, complete revascularization significantly reduced risk for death or MI (relative risk [RR], 0.76; 95% confidence interval [CI], 0.58-0.99; p = 0.04). Meta-regression showed that performing complete revascularization at the time of primary percutaneous coronary intervention (PCI) was associated with better outcomes (p = 0.016). The six trials performing complete revascularization during primary PCI (immediate revascularization) were associated with a significant reduction in risk for both total mortality (RR, 0.62; 95% CI, 0.39-0.97; p = 0.03) and MI (RR, 0.40; 95% CI, 0.25-0.66; p < 0.001), whereas the five trials performing only staged revascularization did not show any significant benefit in either total mortality (RR, 1.02; 95% CI, 0.65-1.62; p = 0.87) or MI (RR, 1.04; 95% CI, 0.48-1.68; p = 0.86).

Conclusions:

The authors concluded that complete revascularization performed during primary PCI was associated with significant reductions in both total mortality and MI.

Perspective:

This meta-analysis of studies comparing complete with culprit-only revascularization for patients with STEMI and multivessel disease reports that complete revascularization significantly reduced the risk for death or MI. Furthermore, trials performing complete revascularization during primary PCI showed a significant benefit for both total mortality and MI, whereas those using a staged revascularization strategy did not show any benefit on these outcomes. When feasible, complete immediate revascularization may be considered in patients with STEMI and multivessel disease while we await the results of the COMPLETE (Complete vs Culprit-only Revascularization to Treat Multivessel Disease After Primary PCI for STEMI) and the FULL REVASC (FFR-Guidance for Complete Non-Culprit Revascularization) trials for more definitive evidence of benefits.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and ACS

Keywords: Acute Coronary Syndrome, Anterior Wall Myocardial Infarction, Mortality, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Risk, Shock, Cardiogenic


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