Complete revascularization reduces cardiovascular death in patients with ST-segment elevation myocardial infarction and multivessel disease: systematic review and meta-analysis of randomized clinical trials

Abstract

Aims The aim of this work was to investigate the prognostic impact of revascularization of non-culprit lesions in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease by performing a meta-analysis of available randomized clinical trials (RCTs). Methods and results Data from six RCTs comparing complete vs. culprit-only revascularization in STEMI patients with multivessel disease were analysed with random effect generic inverse variance method meta-analysis. The endpoints were expressed as hazard ratio (HR) with 95% confidence interval (CI). The primary outcome was cardiovascular death. Main secondary outcomes of interest were all-cause death, myocardial infarction (MI), and repeated coronary revascularization. Overall, 6528 patients were included (3139 complete group, 3389 culprit-only group). After a follow-up ranging between 1 and 3 years (median 2 years), cardiovascular death was significantly reduced in the group receiving complete revascularization (HR 0.62, 95% CI 0.39–0.97, I2 = 29%). The number needed to treat to prevent one cardiovascular death was 70 (95% CI 36–150). The secondary endpoints MI and revascularization were also significantly reduced (HR 0.68, 95% CI 0.55–0.84, I2 = 0% and HR 0.29, 95% CI 0.22–0.38, I2 = 36%, respectively). Needed to treats were 45 (95% CI 37–55) for MI and 8 (95% CI 5–13) for revascularization. All-cause death (HR 0.81, 95% CI 0.56–1.16, I2 = 27%) was not affected by the revascularization strategy. Conclusion In a selected study population of STEMI patients with multivessel disease, a complete revascularization strategy is associated with a reduction in cardiovascular death. This reduction is concomitant with that of MI and the need of repeated revascularization.

Multivessel versus culprit-only PCI in STEMI patients with multivessel disease: meta-analysis of randomized controlled trials

“…Another recently published meta-analysis which also included the data of the COMPLETE trial showed, in contrast to our meta-analysis, a significant reduction of cardiovascular mortality with complete revascularization [ 22 ]. This discrepancy results from different statistical approaches.…”

Non-invasive myocardial work is reduced during transient acute coronary occlusion

“…possible. In this regard, the prognostic relevance of a timely complete coronary revascularization has been repeatedly demonstrated [41][42][43]. Finally, the new non-invasive MWI might be a more sensitive and precise alternative to visual assessment to distinguish between segments that benefited and did not benefit from PCI.…”

SCAI position statement on optimal percutaneous coronary interventional therapy for complex coronary artery disease

“…[20][21][22] However, randomized trial data supporting complete revascularization is only available for ST-elevation myocardial infarction (STEMI) patients undergoing primary PCI, where complete revascularization of significant nonculprit lesions reduces cardiovascular events. 21,23 If complete revascularization by PCI is indicated, a careful assessment of the risk and benefit of this approach is required to optimize patient safety. For patients with multivessel disease, this may require noninvasive ischemia or viability testing, invasive coronary physiologic testing, and considering staged revascularization to reduce the risk of any single procedure.…”

“…Furthermore, complete revascularization in the presence of multivessel CAD is associated with improved long-term clinical outcomes in STEMI. 21,23 Whether complete revascularization should be performed in patients with non-STEMI remains unknown, but maybe supported by observational data. 33 Staging procedures for the treatment of non-culprit stenoses appears to be safe if performed in a timely fashion.…”

“…Multiple observational studies of both CABG and PCI demonstrate that completeness of revascularization is associated with improved outcomes among patients with multivessel disease 20‐22 . However, randomized trial data supporting complete revascularization is only available for ST‐elevation myocardial infarction (STEMI) patients undergoing primary PCI, where complete revascularization of significant nonculprit lesions reduces cardiovascular events 21,23 . If complete revascularization by PCI is indicated, a careful assessment of the risk and benefit of this approach is required to optimize patient safety.…”