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Meta-Analysis Comparing Complete Versus Infarct-Related Artery Revascularization in Patients With ST-Elevation Myocardial Infarction and Multivessel Coronary Disease.

ABSTRACT: A strategy of complete revascularization (CR) versus infarct-related artery revascularization (IRA) in patients with ST-elevation myocardial infarction (STEMI) continues to be a subject of debate. We performed an updated meta-analysis to compare the 2 strategies. Outcomes of interest included major adverse cardiovascular events (MACE), cardiovascular mortality, all-cause mortality, stroke, repeat revascularization, myocardial infarction, and contrast-induced nephropathy. Ten randomized trials including 7,423 patients (CR?=?3,574 and IRA?=?3,849), with a follow-up of 2.0 ± 0.8 years were included. There was a significant reduction in MACE with CR versus IRA (10.7% vs 18.6%, relative risk [RR] 0.64, 95% confidence interval [CI] 0.51 to 0.81, p?=?0.002, I2?=?66%), with higher risk reduction with immediate versus stages revascularization (RR 0.40, 95% CI 0.32 to 0.5 vs RR 0.69, 95% CI 0.54 to 0.89, P-interaction?=?0.002). Complete revascularization was associated with lower rates of repeat revascularization (4.0% vs 11.7%, RR 0.44, 95% CI 0.28 to 0.70, p <0.0001, I2?=?81%), and a nonsignificant trend toward lower cardiovascular mortality (2.8% vs 3.7%, RR 0.78, 95% CI 0.60 to 1.03, p?=?0.08, I2?=?0%). However, there was no difference between the 2 strategies in all-cause mortality (4.6% vs 4.8%, RR 0.90, 95% CI 0.73 to 1.12, p?=?0.36, I2?=?0%), myocardial infarction (5.2% vs 6.5%, RR 0.73, 95% CI, 0.58 to 1.08, p?=?0.08, I2?=?30%), stroke (1.5% vs 1.2%, RR 1.14, 95% CI 0.56 to 2.29, p?=?0.33, I2?=?14%), or contrast-induced nephropathy (1.6% vs 1.2%, RR 1.35, 95% CI 0.85 to 2.15, p?=?0.78, I2?=?0%). In conclusion, CR in patients with STEMI is associated with significant reduction in MACE compared with IRA. This reduction is derived mainly by the low rates of repeat revascularization in the CR group.

SUBMITTER: Osman M

PROVIDER: S-EPMC7453957 | biostudies-literature | 2020 Feb

REPOSITORIES: biostudies-literature

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Meta-Analysis Comparing Complete Versus Infarct-Related Artery Revascularization in Patients With ST-Elevation Myocardial Infarction and Multivessel Coronary Disease.

Osman Mohammed M Khan Safi U SU Farjo Peter D PD Chima Noor N Kheiri Babikir B Zahr Firas F Alkhouli Mohamad M

The American journal of cardiology 20191119 4

A strategy of complete revascularization (CR) versus infarct-related artery revascularization (IRA) in patients with ST-elevation myocardial infarction (STEMI) continues to be a subject of debate. We performed an updated meta-analysis to compare the 2 strategies. Outcomes of interest included major adverse cardiovascular events (MACE), cardiovascular mortality, all-cause mortality, stroke, repeat revascularization, myocardial infarction, and contrast-induced nephropathy. Ten randomized trials in ...[more]

PMID: 31812228

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Project description:Background Data are limited regarding long-term outcomes in patients with ST-segment-elevation myocardial infarction and multivessel disease presenting with cardiogenic shock according to revascularization strategy. We sought to compare the 3-year clinical outcomes of patients with ST-segment-elevation myocardial infarction multivessel disease with cardiogenic shock and patients with multivessel percutaneous coronary intervention (PCI) and infarct-related artery (IRA)-only PCI. Methods and Results Of 13 104 patients from the nationwide, multicenter, prospective KAMIR-NIH (Korea Acute Myocardial Infarction Registry--National Institutes of Health) registry, we selected 659 patients with ST-segment-elevation myocardial infarction who had concomitant non-IRA stenosis and presented with cardiogenic shock. The primary outcome was all-cause death. Multivessel PCI was performed in 260 patients and IRA-only PCI in 399 patients. At 3 years, patients in the multivessel PCI group had a lower risk of all-cause death (adjusted hazard ratio, 0.65; 95% CI, 0.45-0.94 [P=0.024]), all-cause death or MI (adjusted hazard ratio, 0.59; 95% CI, 0.41-0.84 [P=0.004]), and non-IRA repeat revascularization (adjusted hazard ratio, 0.23; 95% CI, 0.10-0.50 [P<0.001]) than those in the IRA-only PCI group. The results were consistent after confounder adjustment by propensity score matching and inverse probability weighting analysis. Landmark analysis at 1 year demonstrated that the multivessel PCI group had a lower risk of recurrent MI and non-IRA repeat revascularization beyond 1 year (log-rank P=0.030 and P=0.017, respectively) than the IRA-only PCI group. Conclusions In patients with ST-segment-elevation myocardial infarction and cardiogenic shock, multivessel PCI was associated with a lower risk of all-cause death than IRA-only PCI at 3 years, suggesting potential benefit of non-IRA revascularization during the index hospitalization to improve long-term clinical outcomes.

Project description:BackgroundRecently, several randomized trials have noted improved outcomes with staged percutaneous coronary intervention (PCI) of nonculprit vessels in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease. However, it remains unclear whether diabetes status affects the outcomes after different revascularization strategies. This study thus compared the impact of diabetes status on long-term outcomes after staged complete revascularization with that after culprit-only PCI.MethodsFrom January 2006 to December 2015, 371 diabetic patients (staged PCI: 164, culprit-only PCI: 207) and 834 nondiabetic patients (staged PCI: 412, culprit-only PCI: 422) with STEMI and multivessel disease were enrolled. The primary endpoint was 5-year major adverse cardiac and cerebrovascular event (MACCE), defined as a composite of all-cause death, myocardial infarction (MI), stroke or unplanned revascularization.ResultsThe rate of the 5-year composite primary endpoint for diabetic patients was close to that for nondiabetic patients (34.5% vs. 33.7%; adjusted hazard ratio [HR] 1.012, 95% confidence interval [CI] 0.815-1.255). In nondiabetic patients, the 5-year risks of MACCE (31.8% vs. 35.5%; adjusted HR 0.638, 95% CI 0.500-0.816), MI (4.6% vs. 9.2%; adjusted HR 0.358, 95% CI 0.200-0.641), unplanned revascularization (19.9% vs. 24.9%; adjusted HR 0.532, 95% CI 0.393-0.720), and the composite of cardiac death, MI or stroke (11.4% vs. 15.2%; adjusted HR 0.621, 95% CI 0.419-0.921) were significantly lower after staged PCI than after culprit-only PCI. In contrast, no significant difference was found between the two groups with respect to MACCE, MI, unplanned revascularization, and the composite of cardiac death, MI or stroke in diabetic patients. Significant interactions were found between diabetes status and revascularization assignment for the composite of cardiac death, MI or stroke (Pinteraction?=?0.013), MI (Pinteraction?=?0.005), and unplanned revascularization (Pinteraction?=?0.013) at 5 years. In addition, the interaction tended to be significant for the primary endpoint of MACCE (Pinteraction?=?0.053). Moreover, the results of propensity score-matching analysis were concordant with the overall analysis in both diabetic and nondiabetic population.ConclusionsIn patients with STEMI and multivessel disease, diabetes is not an independent predictor of adverse cardiovascular events at 5 years. In nondiabetic patients, an approach of staged complete revascularization is superior to culprit-only PCI, whereas the advantage of staged PCI is attenuated in diabetic patients. Trial registration This study was not registered in an open access database.

Project description:Background For patients with ST-segment-elevation myocardial infarction (STEMI) and multivessel coronary artery disease, the optimal treatment of the non-infarct-related artery has been controversial. This up-to-date meta-analysis focusing on individual clinical end points was performed to further evaluate the benefit of complete revascularization with percutaneous coronary intervention for patients with STEMI and multivessel coronary artery disease. Methods and Results We systematically identified all randomized trials comparing complete revascularization with percutaneous coronary intervention to culprit-only revascularization for multivessel disease in STEMI and performed a random-effects meta-analysis. The primary efficacy end point was cardiovascular death analyzed on an intention-to-treat basis. Secondary end points included all-cause mortality, myocardial infarction, and unplanned revascularization. Ten studies (7542 patients) were included: 3664 patients were randomized to complete revascularization and 3878 to culprit-only revascularization. Across all patients, complete revascularization was superior to culprit-only revascularization for reduction in the risk of cardiovascular death (relative risk [RR], 0.68; 95% CI, 0.47-0.98; P=0.037; I2=21.8%) and reduction in the risk of myocardial infarction (RR, 0.65; 95% CI, 0.54-0.79; P<0.0001; I2=0.0%). Complete revascularization also significantly reduced the risk of unplanned revascularization (RR, 0.37; 95% CI, 0.28-0.51; P<0.0001; I2=64.7%). The difference in all-cause mortality with percutaneous coronary intervention was not statistically significant (RR, 0.85; 95% CI, 0.69-1.04; P=0.108; I2=0.0%). Conclusions For patients with STEMI and multivessel disease, complete revascularization with percutaneous coronary intervention significantly improves hard clinical outcomes including cardiovascular death and myocardial infarction. These data have implications for clinical practice guidelines regarding recommendations for complete revascularization following STEMI.

Project description:BackgroundSignificant controversy exists regarding the best approach for nonculprit vessel revascularization in patients with multivessel coronary artery disease presenting with ST-segment elevation myocardial infarction. We conducted a systematic investigation to pool data from current randomized controlled trials (RCTs) to assess optimal treatment strategies in this patient population.Methods and resultsA comprehensive search of SCOPUS from inception through May 2015 was performed using predefined criteria. We compared efficacy and safety outcomes of different approaches by categorizing the studies into 3 groups: (1) complete revascularization (CR) versus culprit lesion revascularization (CL) at index hospitalization, (2) CR at index hospitalization versus staged revascularization (SR) of nonculprit vessels at a separate hospitalization, and (3) comparison of SR versus CL. Eight eligible RCTs met the inclusion criteria: (1) CR versus CL (6 RCTs, n=1727) (2) CR versus SR (3 RCTs, n=311), and (3) SR versus CL (1 RCT, n=149). We observed significantly lower rates of major adverse cardiovascular events, revascularization, and repeat percutaneous coronary interventions among patients treated with CR and SR compared with a CL approach (P<0.05). The rates of all-cause mortality, cause-specific mortality, major bleeding, reinfarction, stroke, and contrast-induced nephropathy did not differ in the CR arm compared with the CL arm. The rates of these outcomes were similar in the CR and SR arms.ConclusionResults suggest that CR and SR compared with CL reduce major adverse cardiovascular event and revascularization rates primarily by lowering repeated percutaneous coronary intervention rates. We did not observe any increase in the rate of adverse events while using a CR or SR strategy compared with a CL approach. Current guidelines discouraging CR need to be reevaluated, and clinical judgment should prevail in treating multivessel coronary artery disease patients with ST-segment elevation myocardial infarction as data from larger RCTs accumulate.

Dataset Information

Meta-Analysis Comparing Complete Versus Infarct-Related Artery Revascularization in Patients With ST-Elevation Myocardial Infarction and Multivessel Coronary Disease.

Publications

Meta-Analysis Comparing Complete Versus Infarct-Related Artery Revascularization in Patients With ST-Elevation Myocardial Infarction and Multivessel Coronary Disease.

Similar Datasets

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