Multivessel versus culprit-only revascularisation in STEMI and multivessel coronary artery disease: meta-analysis of randomised trials
Selected in JACC Cardiovascular Interventions by A. N. Calik
The current meta-analysis study sought to evaluate contemporary randomized trials on multivessel versus IRA-only PCI in patients presenting with STEMI and multivessel CAD.
References
Authors
Atti V, Gwon Y, Narayanan MA, Garcia S, Sandoval Y, Brilakis ES, Basir MB, Turagam MK, Khandelwal A, Mena-Hurtado C, Mamas MA, Abbott JD, Bhatt DL and Velagapudi P
Reference
JACC Cardiovasc Interv. 2020;13(13):1571-1582. doi:10.1016/j.jcin.2020.04.055
Published
July 2020
Link
Read the abstractReviewer
My Comment
Why this study? – the rationale/objective
Nearly half of the patients presenting with ST-segment elevation myocardial infarction (STEMI) have additional angiographically significant lesions in locations separate from that of the infarct-related artery (IRA). Nevertheless, the optimal management of these non-culprit lesions has been subject to many investigations but still confers a matter of debate.
The current meta-analysis study sought to evaluate contemporary randomized trials on multivessel versus IRA-only percutaneous coronary intervention (PCI) in patients presenting with STEMI and multivessel coronary artery disease (CAD).
How was it executed? – the methodology
PubMed, EMBASE, SCOPUS, Google Scholar, and ClinicalTrials.gov were searched for randomised controlled trials (RCT) comparing multivessel PCI with culprit vessel–only PCI in patients with STEMI and multivessel CAD.
The primary efficacy outcomes were selected as all-cause mortality and reinfarction. Secondary efficacy outcomes were cardiovascular mortality and repeat revascularization.
The primary safety outcome was major bleeding and, the secondary safety outcomes were stroke and contrast-induced nephropathy (CIN).
The meta-analysis was performed using a random-effects model to calculate the risk ratio (RR) and 95% confidence interval (CI).
What is the main result?
The current meta-analyses comprised a total of 10 RCTs, including 7,030 patients. While 3,426 of patients underwent complete revascularisation (CR) during the index procedure or in a staged strategy; 3,604 patients received IRA-only revascularisation.
As regards to the efficacy outcomes, no significant difference was found in all-cause mortality between CR and IRA-only revascularisation group (RR: 0.85; 95% CI: 0.68 to 1.05). However, CR was associated with a significant lower risk for reinfarction (RR: 0.69; 95% CI: 0.50 to 0.95), cardiovascular mortality (RR: 0.71; 95% CI: 0.50 to 1.00), and repeat revascularisation (RR: 0.34; 95% CI: 0.25 to 0.44) compared to IRA-only PCI revascularisation strategy.
Illustration credit: JACC Cardiovascular Interventions
The safety outcomes, defined as major bleeding, CIN and stroke, were found to be similar between two groups.
Sensitivity analysis of 1,964 patients from 5 clinical trials including multivessel PCI during ‘index hospitalisation’ demonstrated a 49% relative risk reduction in cardiovascular mortality, a 38% reduction in all-cause mortality, and a 64% reduction in repeat revascularisation, with a similar risk for stroke and major bleeding.
Critical reading and the relevance for clinical practice
This meta-analysis delivers a clear message in favour of complete revascularisation in patients presenting with STEMI and multivessel disease. Despite no difference in all-cause mortality, CR approach found to be associated with a reduced risk for cardiovascular mortality (29%), reinfarction (31%) and repeat revascularisation (66%), without any safety concern.
The authors also tried to find an answer for the best timing of revascularisation for non-culprit lesions. They concluded that the complete revascularisation during ‘index hospitalisation’ was associated with lower repeat revascularisation, cardiovascular mortality and all-cause death.
Based on these findings, multivessel PCI appears to be a reasonable strategy among patients with STEMI and multivessel CAD, but there are still questions to be answered. One should keep in mind that the current study does not apply to STEMI patients in cardiogenic shock and late STEMI presenters. Also, more studies are needed to clarify which non-culprit lesion and when to revascularise, even partially answered in the current meta-analysis. With the ability to determine high-risk unstable plaques, intravascular imaging may assist angiographic and hemodynamic assessment while deciding on the non-culprit lesions for revascularisation.
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