The optimal timing for non-culprit percutaneous coronary intervention in patients with multivessel coronary artery disease: A pairwise and network meta-analysis of randomized trials

Abstract

Background and aimsRecently, several randomized trials have shown that patients with multivessel disease (MVD) often pursue complete revascularization during percutaneous coronary intervention (PCI) to improve their prognosis. However, the optimal time for the non-culprit artery has been controversial. This study aimed to determine the optimal strategy for revascularization in ST-segment elevation myocardial infarction (STEMI) patients with multivessel coronary artery disease (CAD).MethodsRandomized controlled trials (RCTs) comparing three revascularization strategies [i.e., complete revascularization at the index procedure (CR), complete revascularization as a staged procedure (SR), or culprit-only revascularization (COR)] in STEMI patients with multivessel coronary artery disease were included. We performed both pairwise and network meta-analyses. Network meta-analysis was performed using mixed treatment comparison models.Results17 trials with 8568 patients were included. In the network meta-analysis, the most interesting finding was that staged revascularization increased the risk of major adverse cardiac events (MACE) compared with complete revascularization at the index procedure [odds ratio (OR): 1.93; 95% confidence interval (CI): 1.07–3.49]. In the pairwise meta-analysis, complete revascularization reduced the incidence of MACE [risk ratio (RR): 0.62, 95% CI: 0.48–0.79, p < 0.001], mainly because it reduced the probability of unplanned repeat revascularization (RR: 0.49, 95% CI: 0.33–0.75, p = 0.001). There were no significant differences in all-cause mortality, cardiac mortality, or nonfatal re-myocardial infarction (MI).ConclusionOur analysis suggests that complete revascularization should be performed in STEMI patients with multivessel coronary artery disease, and complete revascularization at the index procedure is superior to staged revascularization in reducing the risk of MACE events.

Immediate vs. multistage revascularization of non-infarct coronary artery(-ies) in patients with hemodynamically stable multivessel disease acute myocardial infarction: a systematic review and meta-analysis

“…In the MULTISTAIRS AMI trial, the non-inferiority of immediate complete revascularization was driven by the significantly lower occurrence of nonfatal MI and unplanned ischemia-driven revascularization. A pairwise and network meta-analysis comparing three different revascularization strategies among multivessel STEMI patients showed that complete revascularization at the time of primary PCI was superior to complete revascularization as a staged procedure in terms of MACE [41]. MACCE following the immediate complete revascularization strategy in multivessel AMI patients is hypothesized to be affected by longer procedure duration, higher contrast volume administered during the index procedure, a possible higher rate of complications (periprocedural MI, procedure-related stroke, bleeding requiring transfusion, and contrast-induced nephropathy requiring dialysis) and thus rendering it non-inferior to the staged complete revascularization strategy.…”

Quantitative Flow Ratio for Assessment of Non-Culprit Coronary Artery Lesions During Percutaneous Coronary Intervention (PCI) in 79 Patients Diagnosed with ST-Elevation Myocardial Infarction (STEMI): A Study from a Single Center in Lithuania

“…In our center, we discussed good QFR suitability and comfortability for patients with STEMI but did not know that the correlation between index PCI QFR and staged PCI QFR would be very high. Nevertheless, only 1 of the 105 acute QFRs disagreed with clinical treatment decision-making, and it is perfect because interventional cardiologists are increasingly discussing non-culprit PCI during infarct-related artery PCI [ 22 ]. Our results demonstrated that it is reliable and Ullrich et al showed that it decreases angina symptoms and improves the patient’s prognosis.…”