Culprit Vessel Only Versus Multivessel and Staged Percutaneous Coronary Intervention for Multivessel Disease in Patients Presenting With ST-Segment Elevation Myocardial Infarction: A Pairwise and Network Meta-Analysis

Aug 01, 2011
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Authors:
Vlaar PJ, Mahmoud KD, Holmes DR Jr., et al.
Citation:
J Am Coll Cardiol 2011;58:692-703.
Summary By:
Debabrata Mukherjee, MD, FACC

Study Questions:

What is the optimal treatment strategy for nonculprit vessel stenosis in patients presenting with ST-segment elevation myocardial infarction (STEMI)?

Methods:

Pairwise and network meta-analyses were performed on three percutaneous coronary intervention (PCI) strategies for multivessel disease (MVD) in STEMI patients: 1) culprit vessel only PCI strategy (culprit PCI), defined as PCI confined to culprit vessel lesions only; 2) multivessel PCI strategy (MV-PCI), defined as PCI of culprit vessel as well as ≥1 nonculprit vessel lesions; and 3) staged PCI strategy (staged PCI), defined as PCI confined to culprit vessel, after which ≥1 nonculprit vessel lesions are treated during staged procedures. Prospective and retrospective studies were included when research subjects were patients with STEMI and MVD undergoing PCI. The primary endpoint was short-term mortality. For the direct pairwise meta-analyses, pooled estimates and 95% confidence intervals were calculated assuming a random-effects model with inverse variance weighting using the DerSimonian and Laird method to account for heterogeneity.

Results:

Four prospective and 14 retrospective studies involving 40,280 patients were included. Pairwise meta-analyses demonstrated that staged PCI was associated with lower short- and long-term mortality, as compared with culprit PCI and MV-PCI, and that MV-PCI was associated with the highest mortality rates at both short- and long-term follow-up. In network analyses, staged PCI was also consistently associated with lower mortality.

Conclusions:

The authors concluded that this analysis supports current guidelines discouraging performance of multivessel primary PCI for STEMI.

Perspective:

This meta-analysis supports current American College of Cardiology Foundation/American Heart Association guidelines advising the performance of primary PCI for STEMI confined to the culprit vessel only. Based on these data, MV-PCI should be discouraged, and significant nonculprit vessel lesions should only be treated during planned staged procedures. Additional research is indicated to define the optimal revascularization strategy in patients with both hemodynamic stable and unstable STEMI and MVD, and needs to compare outcomes between coronary artery bypass grafting versus culprit PCI versus staged PCI versus MV-PCI. In the interim, staged PCI should be considered the optimal treatment strategy with additional noninvasive ischemic assessment or fractional flow reserve performed for intermediate lesions.

Keywords: Myocardial Infarction, Follow-Up Studies, Constriction, Pathologic, Coronary Artery Bypass, Hemodynamics, United States, Percutaneous Coronary Intervention


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