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Optimal Revascularization Strategy in Non-ST-Segment-Elevation Myocardial Infarction With Multivessel Coronary Artery Disease: Culprit-Only Versus One-Stage Versus Multistage Revascularization.

ABSTRACT: Background Few studies have investigated optimal revascularization strategies in non-ST-segment-elevation myocardial infarction with multivessel disease. We investigated 3-year clinical outcomes according to revascularization strategy in patients with non-ST-segment-elevation myocardial infarction and multivessel disease. Methods and Results This retrospective, observational, multicenter study included patients with non-ST-segment-elevation myocardial infarction and multivessel disease without cardiogenic shock. Data were analyzed at 3 years according to the percutaneous coronary intervention strategy: culprit-only revascularization (COR), 1-stage multivessel revascularization (MVR), and multistage MVR. The primary outcome was major adverse cardiac events (MACE: a composite of all-cause death, nonfatal spontaneous myocardial infarction, or any repeat revascularization). The COR group had a higher risk of MACE than those involving other strategies (COR versus 1-stage MVR; hazard ratio, 0.65; 95% CI, 0.54-0.77; P<0.001; and COR versus multistage MVR; hazard ratio, 0.74; 95% CI, 0.57-0.97; P=0.027). There was no significant difference in the incidence of MACE between 1-stage and multistage MVR (hazard ratio, 1.14; 95% CI, 0.86-1.51; P=0.355). The results were consistent after multivariate regression, propensity score matching, inverse probability weighting, and Bayesian proportional hazards modeling. In subgroup analyses stratified by the Global Registry of Acute Coronary Events score, 1-stage MVR lowered the risk of MACE compared with multistage MVR in low-to-intermediate risk patients but not in patients at high risk. Conclusions MVR reduced 3-year MACE in patients with non-ST-segment-elevation myocardial infarction and multivessel disease compared with COR. However, 1-stage MVR was not superior to multistage MVR for reducing MACE except in low-to-intermediate risk patients.

SUBMITTER: Kim MC

PROVIDER: S-EPMC7792267 | biostudies-literature | 2020 Aug

REPOSITORIES: biostudies-literature

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Optimal Revascularization Strategy in Non-ST-Segment-Elevation Myocardial Infarction With Multivessel Coronary Artery Disease: Culprit-Only Versus One-Stage Versus Multistage Revascularization.

Kim Min Chul MC Hyun Ju Yong JY Ahn Youngkeun Y Bae SungA S Hyun Dae Young DY Cho Kyung Hoon KH Sim Doo Sun DS Hong Young Joon YJ Kim Ju Han JH Jeong Myung Ho MH Kim Hyo-Soo HS Gwon Hyeon Cheol HC Seong In Whan IW Hwang Kyoung-Kook KK Chae Shung Chull SC Hur Seung Ho SH Cha Kwang Soo KS Oh Seok Kyu SK

Journal of the American Heart Association 20200731 15

Background Few studies have investigated optimal revascularization strategies in non-ST-segment-elevation myocardial infarction with multivessel disease. We investigated 3-year clinical outcomes according to revascularization strategy in patients with non-ST-segment-elevation myocardial infarction and multivessel disease. Methods and Results This retrospective, observational, multicenter study included patients with non-ST-segment-elevation myocardial infarction and multivessel disease without c ...[more]

PMID: 32750302

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Project description:Background: The relative benefit of immediate complete revascularization, staged complete revascularization, and culprit-only percutaneous coronary intervention (PCI) remains unclear in hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease. The aim of this study was to compare the clinical outcomes of the 3 PCI strategies in this population. Methods: We followed a pre-specified protocol (PROSPERO number: CRD42020183801). A comprehensive search of the electronic databases including PubMed, EMBASE and Cochrane Library from inception through February 21, 2020 was conducted. Randomized trials evaluating the comparative efficacy and safety of at least 2 of the 3 PCI strategies were identified. The primary endpoint was the composite of cardiovascular mortality or myocardial infarction (MI) during the longest follow-up. Pairwise and network meta-analyses were performed with random-effects model. Results: Eleven trials including 6,942 patients were analyzed. Pairwise meta-analysis noted that immediate complete revascularization and staged complete revascularization were respectively associated with a 52 and 27% reduction in the risk of cardiovascular death or MI (relative risk [RR] 0.48, 95% confidence interval [CI] 0.32-0.73, I2 = 0%; and RR 0.73, 95% CI 0.61-0.88, I2 = 0%, respectively), compared with culprit-only PCI. The risk of cardiovascular death or MI was not statistically different in staged and immediate complete revascularization groups (RR 0.88, 95% CI 0.45-1.72, I2 = 0%). Network meta-analysis obtained almost similar results compared with pairwise meta-analysis, and immediate complete revascularization had a 77% probability of being the best strategy for reducing cardiovascular death or MI among the 3 PCI strategies. Conclusion: The current evidence suggests that both immediate and staged complete revascularization were associated with a reduction of cardiovascular death or MI compared with culprit-only PCI. Further trials are warranted to directly compare immediate vs. staged complete revascularization in this population. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, PROSPERO [CRD42020183801].

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:Introduction:The optimal revascularization strategy for patients with ST-segment elevation myocardial infarction and multivessel disease is unclear. In this study, we performed a meta-analysis to determine the optimal revascularization strategy for treating these patients. Methods:Searches of PubMed, the Cochrane Library, clinicaltrial.gov, and the reference lists of relevant papers were performed covering the period between the year 2000 and March 20, 2017. A pairwise analysis and a Bayesian network meta-analysis were performed to compare the effectiveness of early complete revascularization (CR) during the index hospitalization, delayed CR, and culprit only revascularization (COR). The primary endpoint was the incidence of major adverse cardiac events (MACE), which were defined as the composite of recurrent myocardial infarction (MI), repeat revascularization, and all-cause mortality. The secondary endpoints were the rates of all-cause mortality, recurrent MI, and repeat revascularization. This study is registered at PROSPERO under registration number CRD42017059980. Results:Eleven randomized controlled trials including a total of 3,170 patients were identified. A pairwise meta-analysis showed that compared with COR, early CR was associated with significantly decreased risks of MACE (relative risk [RR] 0.47, 95% CI 0.39-0.56), MI (RR 0.55, 95% CI 0.37-0.83), and repeat revascularization (RR 0.35, 95% CI 0.27-0.46) but not of all-cause mortality (RR 0.78, 95% CI 0.52-1.16). These results were confirmed by trial sequential analysis. The network meta-analysis showed that early CR had the highest probability of being the first treatment option during MACE (89.2%), MI (83.3%), and repeat revascularization (80.4%). Conclusion:Early CR during the index hospitalization was markedly superior to COR with respect to reducing the risk of MACE, as CR significantly decreased the risks of MI and repeat revascularization compared with COR. However, further study is warranted to determine whether CR during the index hospitalization can improve survival in patients with concurrent ST-segment elevation myocardial infarction and multivessel disease. The optimal timing of CR remains inconclusive considering the small number of studies and patients included in the analysis comparing early and delayed CR.

Project description:Background and aimsThe optimal interventional strategy remains undetermined in hemodynamically stable patients with NSTEMI and MVD. This study aimed to examine clinical prognosis among culprit vessel, immediate multivessel, and staged percutaneous coronary intervention (PCI) in patients with NSTEMI and MVD.MethodsThis retrospective, observational, single-center study included 943 hemodynamically stable patients with NSTEMI and MVD who had undergone successful drug-eluting stent (DES) implantation from January 2014 to December 2019. Patients were categorized into culprit lesion-only PCI (CL-PCI), immediate multivessel PCI (MV-PCI), and out-of-hospital staged MV-PCI according to PCI strategy. The primary outcome was the composite of major adverse cardiac events (MACEs), including all-cause death, myocardial infarction (MI), or unplanned repeat revascularization. The secondary outcomes were all-cause death, cardiac death, MI, and unplanned repeat revascularization.ResultsOver a median follow-up of 59 months, immediate MV-PCI was associated with a lower risk of all-cause death than CL-PCI (HR: 0.591, 95%CI: 0.364-0.960, P = 0.034). Out-of-hospital staged MV-PCI was associated with a reduced risk of MACE (HR: 0.448, 95%CI: 0.314-0.638, P < 0.001) and all-cause death (HR: 0.326, 95%CI: 0.183-0.584, P < 0.001) compared with CL-PCI. The above results were accordant after multivariate COX analysis and propensity score matching. MACE (HR: 0.560, 95%CI: 0.385-0.813, P = 0.002) and repeat revascularization (HR: 0.627, 95%CI: 0.400-0.982, P = 0.041) were significantly less likely to occur with out-of-hospital MV-PCI rather than immediate MV-PCI. However, the incidences of primary and secondary outcomes were comparable between immediate and staged PCI after confounder adjustment using multivariate regression and propensity score matching analysis. For subgroup analyses stratified by synergy between PCI with taxus and cardiac surgery score, staged MV-PCI was found to lower the risk of MACE compared with immediate MV-PCI in patients with more complex coronary disease.ConclusionHemodynamically stable patients with NSTEMI and MVD benefited from the strategy of MV-PCI. Patients with complex coronary anatomy treated with out-of-hospital staged MV-PCI rather than immediate MV-PCI had lower risks of MACE. These need to be confirmed in the future randomized study.

Dataset Information

Optimal Revascularization Strategy in Non-ST-Segment-Elevation Myocardial Infarction With Multivessel Coronary Artery Disease: Culprit-Only Versus One-Stage Versus Multistage Revascularization.

Publications

Optimal Revascularization Strategy in Non-ST-Segment-Elevation Myocardial Infarction With Multivessel Coronary Artery Disease: Culprit-Only Versus One-Stage Versus Multistage Revascularization.

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