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Multivessel vs. Culprit Vessel–Only PCI in STEMI
Quick Takes
- Among patients presenting with STEMI, a strategy of multivessel PCI was associated with a 31% lower risk for reinfarction, with no significant difference in all-cause mortality.
- Additional studies should evaluate the optimal timing of non–culprit vessel revascularization in patients with STEMI.
- These results do not apply to STEMI patients in cardiogenic shock, where increased mortality has been shown with multivessel PCI in the CULPRIT-SHOCK trial.
Study Questions:
What is the efficacy and safety of multivessel versus culprit vessel–only percutaneous coronary intervention (PCI) among patients presenting with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD)?
Methods:
The investigators conducted a comprehensive search for published randomized controlled trials comparing multivessel PCI with culprit vessel–only PCI on ClinicalTrials.gov, PubMed, Web of Science, EBSCO Services, the Cochrane Central Register of Controlled Trials, Google Scholar, and scientific conference sessions from inception to September 15, 2019. A meta-analysis was performed using a random-effects model to calculate the risk ratio (RR) and 95% confidence interval (CI). Primary efficacy outcomes were all-cause mortality and reinfarction.
Results:
Ten randomized controlled trials were included, representing 7,030 patients: 3,426 underwent multivessel PCI and 3,604 received culprit vessel–only PCI. Compared with culprit vessel–only PCI, multivessel PCI was associated with no significant difference in all-cause mortality (RR, 0.85; 95% CI, 0.68-1.05) and lower risk for reinfarction (RR, 0.69; 95% CI, 0.50-0.95), cardiovascular mortality (RR, 0.71; 95% CI, 0.50-1.00), and repeat revascularization (RR, 0.34; 95% CI, 0.25-0.44). Major bleeding (RR, 0.92; 95% CI, 0.50-1.67), stroke (RR, 1.15; 95% CI, 0.65-2.01), and contrast-induced nephropathy (RR, 1.25; 95% CI, 0.80-1.95) were not significantly different between the two groups.
Conclusions:
The authors concluded that multivessel PCI was associated with a lower risk for reinfarction, without any difference in all-cause mortality, compared with culprit vessel–only PCI in patients with STEMI.
Perspective:
This meta-analysis of 10 randomized controlled trials reports that among STEMI patients, a strategy of multivessel PCI was associated with a 31% lower risk for reinfarction, with no significant difference in all-cause mortality. In addition, there was lower risk for CV mortality and for repeat revascularization with multivessel PCI, without any difference in major adverse events of bleeding, stroke, or contrast-induced nephropathy. Based on these and other data, multivessel PCI appears to be a reasonable strategy among patients with STEMI and multivessel CAD, but the timing of revascularization remains controversial. Additional studies should evaluate the optimal timing of nonculprit vessel revascularization in patients with STEMI. Of importance, these results do not apply to MI patients in cardiogenic shock, where increased mortality has been shown with multivessel PCI in the CULPRIT-SHOCK trial.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Stable Ischemic Heart Disease, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Acute Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Vascular Medicine, Chronic Angina
Keywords: Acute Coronary Syndrome, Coronary Artery Disease, Hemorrhage, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Risk, Secondary Prevention, Shock, Cardiogenic, ST Elevation Myocardial Infarction
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