Safety and feasibility of complete simultaneous revascularization during primary PCI in patients with STEMI and multi-vessel disease

Immediate Versus Staged Complete Revascularization in Patients Presenting with Acute Coronary Syndrome and Multivessel Coronary Disease Without Cardiac Shock: A Study-Level Meta-analysis of Randomized Controlled Trials

BACKGROUND

Achieving full revascularization via percutaneous coronary intervention (PCI) may enhance the prognosis of individuals diagnosed with acute coronary syndrome (ACS) and multivessel coronary disease (MVD). The present work focused on investigating whether PCI should be performed during staged or index procedures for non-culprit lesions.

METHODS

Electronic databases, such as PubMed, EMBASE, the Cochrane Library, and Web of Science, were systematically explored to locate studies contrasting immediate revascularization with staged complete revascularization for patients who experienced ACS and MVD without cardiac shock. The outcome measures comprised major adverse cardiovascular events (MACEs), all-cause mortality, cardiovascular mortality, myocardial infarction (MI), stroke, and unplanned ischemia-driven revascularization (UIDR).

RESULTS

Nine randomized controlled trials involving 3550 patients, including 1780 who received immediate complete revascularization (ICR) and 1770 who received staged complete revascularization (SCR), were included in the analysis. The ICR group had lower MACEs (RR: 0.73, 95% CI: 0.61~0.87, P = 0.0004), MI (RR: 0.53, 95% CI: 0.37~0.77, P = 0.0008), and UIDR (RR: 0.64, 95% CI: 0.50~0.81, P = 0.0003) than did the SCR group. All-cause mortality, CVD incidence, and stroke incidence did not significantly differ between the two groups. According to our subgroup analyses based on the time window of the SCR, the ICR group had significantly fewer MACEs (RR: 0.70, 95% CI: 0.56~0.88, P = 0.003), MI (RR: 0.53, 95% CI: 0.37~0.77, P = 0.0002), and UIDR (RR: 0.56, 95% CI: 0.40~0.77, P = 0.0004) than did the subgroup of patients who were between discharge and 45 days.

CONCLUSION

Compared with patients in the SCR group, patients in the ICR group had decreased MACEs, MI, and UIDR, especially between discharge and 45 days. All-cause mortality and CVD incidence were not significantly different between the two groups.

Immediate Versus Staged Complete Revascularization in Patients With Acute Coronary Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

A strategy of complete revascularization (CR) is recommended in patients with acute coronary syndrome (ACS) and multivessel disease (MVD). However, the optimal timing of CR remains equivocal. We searched MEDLINE, Embase, the Cochrane Library, and ClinicalTrials.gov for randomized controlled trials (RCTs) comparing immediate CR (ICR) with staged CR in patients with ACS and MVD. Our primary outcomes were all-cause and cardiovascular mortality. All outcomes were assessed at 3 time points: in-hospital or at 30 days, at 6 months to 1 year, and at >1 year. Data were pooled in RevMan 5.4 using risk ratios as the effect measure. A total of 9 RCTs (7,506 patients) were included in our review. A total of 7 trials enrolled patients with ST-segment elevation myocardial infarction (STEMI), 1 enrolled patients with non-STEMI only, and 1 enrolled patients with all types of ACS. There was no difference between ICR and staged CR regarding all-cause and cardiovascular mortality at any time window. ICR reduced the rate of myocardial infarction and decreased the rate of repeat revascularization at 6 months and beyond. The rates of cerebrovascular events and stent thrombosis were similar between the 2 groups. In conclusion, the present meta-analysis demonstrated a lower rate of myocardial infarction and a reduction in repeat revascularization at and after 6 months with ICR strategy in patients with mainly STEMI and MVD. The 2 groups had no difference in the risk of all-cause and cardiovascular mortality. Further RCTs are needed to provide more definitive conclusions and investigate CR strategies in other ACS.

Meta-analysis of immediate complete vs staged complete revascularization in patients with acute coronary syndrome and multivessel disease

BACKGROUND

Randomized controlled trials (RCTs) have shown varying results between immediate and staged complete percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) and multivessel disease (MVD). We conducted a meta-analysis to reconcile the findings.

METHODS

Online databases were searched for RCTs comparing immediate vs staged complete PCI in patients presenting with ACS. The outcomes of interest were major adverse cardiovascular events (MACE), all cause death, myocardial infarction (MI), cardiovascular death, stent thrombosis, target vessel revascularization (TVR), cerebrovascular events, bleeding and acute kidney injury (AKI)/contrast induced nephropathy (CIN). Risk ratios (RR) with 95 % confidence intervals (CI) were calculated using the random-effects model.

RESULTS

Nine RCTs with a total of 3637 patients - 1821 in the immediate PCI group and 1816 in the staged PCI group, were included. The mean age was 64 years, 78 % of patients were men and the mean duration of follow up was 1 year. As compared with staged complete PCI, the immediate PCI group was associated with significant reduction of MI (RR 0.53, 95 % CI 0.36-0.77) and TVR (RR 0.69, 95 % CI 0.53-0.90). The risks of all-cause death, cardiovascular death, MACE, cerebrovascular events, stent thrombosis, bleeding and AKI/CIN were similar in the two groups.

CONCLUSIONS

In ACS patients selected for complete revascularization strategy, multivessel PCI during the index procedure may be associated with significant reduction in the risk of MI and TVR without harm when compared with a staged PCI strategy.

Comparison of Immediate Versus Staged Complete Revascularisation in Patients Presenting With Acute Coronary Syndrome and Multivessel Disease: A Meta-Analysis of Randomized and Non-randomized Studies

Acute myocardial infarction is a critical medical condition that poses a significant health burden, leading to substantial morbidity. Despite advancements in medical care, managing this condition is challenging for patients and society. The preferred approach appears to be comprehensive multivessel revascularization, yet the optimal timing remains uncertain. This study aims to compare immediate complete revascularisation and stage complete vascularization in patients presenting with acute coronary syndrome (ACS) and multivessel coronary artery disease (MVD). The Preferred Reporting of Systematic Reviews and Meta-analysis (PRISMA) guidelines conducted the present meta-analysis. A comprehensive literature search was conducted using online databases, including PubMed, and EMBASE from 2010 onwards, to identify articles that compared cardiovascular outcomes between patients undergoing immediate and staged complete revascularization. We also searched Google Scholar for additional studies relevant to the present meta-analysis. The primary outcome assessed in this study was major adverse cardiovascular events (MACE). Secondary outcomes included all-cause mortality, cardiovascular mortality, myocardial infarction (MI), and revascularization. A total of 15 studies fulfilled pre-defined eligibility criteria and were included in the final analysis. Our analysis shows that staged revascularization is associated with improved outcomes in patients with ACS and multivessel CAD, including all-cause mortality and cardiovascular mortality, without increasing the risk of major adverse cardiovascular events, myocardial infarction, and the need for unplanned revascularization.

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

Background and aims

Recently, 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).

Methods

Randomized 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.

Results

17 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).

Conclusion

Our 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 versus staged revascularisation of non-culprit arteries in patients with acute coronary syndrome: a systematic review and meta-analysis

Although there is robust evidence that revascularisation of non-culprit vessels should be pursued in patients presenting with an acute coronary syndrome (ACS) and multivessel coronary artery disease (MVD), the optimal timing of complete revascularisation remains disputed. In this systematic review and meta-analysis our results suggest that outcomes are comparable for immediate and staged complete revascularisation in patients with ACS and MVD. However, evidence from randomised controlled trials remains scarce and cautious interpretation of these results is recommended. More non-biased evidence is necessary to aid future decision making on the optimal timing of complete revascularisation.

The optimal percutaneous coronary intervention strategy for patients with ST-segment elevation myocardial infarction and multivessel disease: a pairwise and network meta-analysis

Objective:

To investigate the optimal percutaneous coronary intervention (PCI) strategy in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease.

Methods:

Trials that randomized patients with STEMI and multivessel coronary artery disease to immediate multivessel PCI, staged multivessel PCI, or culprit-only PCI and prospective observational studies that investigated all-cause death were included. Random effect risk ratio (RR) and 95% confidence interval (CI) were calculated.

Results:

A total of 13 randomized trials with 7627 patients and 21 prospective observational studies with 60311 patients were included. In the pairwise and network meta-analysis based on randomized trials, immediate or staged multivessel PCI was associated with a lower risk of long-term major adverse cardiac events (MACE; RR: 0.58; 95% CI: 0.45 to 0.74) than culprit-only PCI, which was mainly due to lower risks of myocardial infarction (RR: 0.67; 95% CI: 0.51 to 0.88) and revascularization (RR: 0.38; 95% CI: 0.28 to 0.51), without any significant difference in all-cause death (RR: 0.85; 95% CI: 0.69 to 1.04; I² = 0.0%). However, short-term outcomes were deficient in randomized trials. The results from real-world prospective observational studies suggested that staged multivessel PCI reduced long-term all-cause death (RR: 0.53; 95% CI: 0.39 to 0.71; I² = 15.6%), whereas immediate multivessel PCI increased short-term all-cause death (RR: 1.58; 95% CI: 1.22 to 2.05; I² = 43.8%) relative to culprit-only PCI.

Conclusion:

For patients in randomized trials, multivessel PCI in an immediate or staged procedure was preferred due to improvements in long-term outcomes. As a supplement, the results in real-world patients derived from prospective observational studies suggested that staged multivessel PCI was superior to immediate multivessel PCI. Therefore, staged multivessel PCI may be the optimal PCI strategy for patients with STEMI and multivessel coronary artery disease.

Optimal Revascularization Strategy for Patients With ST-segment Elevation Myocardial Infarction and Multivessel Disease: A Pairwise and Network Meta-Analysis

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].

Comparative Effectiveness of Complete Revascularization Strategies in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Disease: A Bayesian Network Meta-Analysis

Whether fractional flow reserve (FFR) should be available for revascularization in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) is controversial. We aimed to compare the efficacy of various complete revascularization (CR) regimens for STEMI patients with MVD. The PubMed and Cochrane Library databases and clinicaltrial.gov were searched for the randomized controlled trials (RCTs) comparing the FFR-guided CR, angiography-guided CR, and culprit-only revascularization (COR) strategies in STEMI patients with MVD. A Bayesian random-effect model was employed to synthesize the evidence in network meta-analysis. We used relative risk (RR) and 95% credible interval (CrI) as measures of effect size. The primary endpoint was the composite outcome of all-cause mortality or myocardial infarction (MI). Twelve RCTs were included. Angiography-guided CR showed a lower event rate of the composite outcome (RR, 0.68; 95%CrI, 0.50–0.87), all-cause mortality (RR, 0.75; 95%CrI, 0.55–0.96), MI (RR, 0.63; 95%CrI, 0.43–0.86), and repeat revascularization (RR, 0.36; 95% CrI, 0.24–0.55) compared with COR. Additionally, angiography-guided CR had a lower risk of primary outcome (RR, 0.64; 95%CrI, 0.38–0.94) and MI (RR, 0.58; 95%CrI, 0.31–0.92) than FFR-guided CR. The difference between the FFR-guided CR and COR in terms of composite outcome, all-cause mortality, and MI was similar. Angiography-guided CR was associated with the highest probability of optimal treatment for the primary outcome (98.5%), followed by FFR-guided CR (1.2%) and COR (0.3%). STEMI patients with MVD benefitted more from angiography-guided CR than from FFR-guided CR. However, only one study compared the effectiveness of FFR-guided and angiography-guided PCI; thus, the comparison between FFR-guided and angiography-guided PCI relied on indirect evidence. Therefore, further studies directly comparing the effectiveness of these two CR strategies are warranted.

Immediate Versus Staged Multivessel PCI Strategies in Patients with ST-Segment Elevation Myocardial Infarction and Multivessel Disease: A Systematic Review and Meta-analysis

BACKGROUND

Recent guidelines and randomized clinical trials favor the multivessel percutaneous coronary intervention (MV-PCI) strategy undertaken immediately or staged after primary PCI in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease. However, the optimal strategy of MV-PCI remains unknown.

METHODS

We conducted a search of PUBMED, EMBASE, Web of Science, the Cochrane database (CENTRAL), clinicaltrial.gov, and Google Scholar for studies comparing immediate versus staged MV-PCI in patients with STEMI and multivessel disease. Pooled odds ratios (OR) and 95% confidence intervals (CI) were estimated using random-effects models.

RESULTS

Eighteen (4 randomized clinical trials) studies with 8,100 patients fulfilled the inclusion criteria. Relative to staged MV-PCI, immediate MV-PCI was associated with higher short-term (within 30 days) (OR, 3.96; 95% CI, 2.07-7.59; P<0.0001) and long-term (above 6 months) mortality (OR, 2.12; 95% CI, 1.46-3.07; P<0.0001), short-term major adverse cardiovascular events (MACE)(OR, 1.99; 95% CI, 1.13-3.50; P=0.02) and cardiac death (OR, 4.78; 95% CI, 2.17-10.53; P=0.0001). There was a nonsignificant trend towards higher long-term MACE (OR, 1.23; 95% CI, 0.98-1.54; P=0.07) and cardiac death (OR, 1.75; 95% CI, 0.93-3.30; P=0.08) with immediate versus staged MV-PCI. Revascularization, myocardial infarction, and safety endpoints including stroke, major bleeding, and renal failure were similar between immediate versus staged MV-PCI. However, pooled analysis of randomized clinical trials did not show any significant differences in long-term MACE, all-cause mortality, myocardial infarction, and revascularization.

CONCLUSIONS

Our meta-analysis suggests that among patients with STEMI and multivessel disease, staged instead of immediate MV-PCI may be the optimal revascularization strategy.

Percutaneous complete revascularization strategies using sirolimus-eluting biodegradable polymer-coated stents in patients presenting with acute coronary syndrome and multivessel disease: Rationale and design of the BIOVASC trial

BACKGROUND

Complete revascularization in patients with an acute coronary syndrome and multivessel disease is superior compared to culprit-only treatment. However, it is unknown whether direct complete or staged complete revascularization should be pursued.

METHODS

The BIOVASC study is an investigator-initiated, prospective, multicenter, randomized, 2-arm, international, open-label, noninferiority trial. We will randomize 1,525 patients 1:1 to immediate complete revascularization (experimental arm) or culprit-only plus staged complete revascularization (control arm). Patients will be enrolled in approximately 30 sites in Belgium, Italy, the Netherlands, and Spain. The primary end point is a composite of all-cause mortality, nonfatal myocardial infarction, any unplanned ischemia-driven revascularization (excluding staged procedures in the control arm at the predetermined time), and cerebrovascular events (MACCE) at 1 year post index procedure.

CONCLUSIONS

The BIOVASC study aims to further refine the treatment algorithm for acute coronary syndrome patients with multivessel disease in terms of optimal timing for complete revascularization (Clinicaltrials.gov NCT03621501).

Complete Versus Culprit-Only Revascularization in STEMI: a Contemporary Review

PURPOSE OF REVIEW

In ST-segment elevation myocardial infarction, urgent revascularization of the culprit coronary vessel and restoration of coronary flow is the goal of the initial management. However, obstructive non-culprit disease is frequently concomitantly found during initial angiography and portends a poor prognosis. Management of non-culprit lesions in ST-segment elevation myocardial infarction (STEMI) has been the subject of extensive debate. This review will examine the currently available evidence, with a specific focus on randomized clinical trials performed to date.

RECENT FINDINGS

Although early observational data suggested better outcomes with culprit-only revascularization, more recent data from several randomized trials have suggested improved outcomes with complete multivessel revascularization, either during the index PCI procedure or as a staged procedure. Data from recent randomized controlled trials have suggested the superiority of complete or multivessel revascularization and have subsequently led to changes to the most recent iterations of STEMI guidelines. However, the optimal management and timing of revascularization of non-culprit lesions in STEMI remain controversial.

Non-infarct related artery revascularization in ST-segment elevation myocardial infarction patients with multivessel disease

PURPOSE OF REVIEW

Multivessel disease (MVD) is common in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) and is associated with significant risk of future cardiovascular (CV) events including short and longer-term mortality. In this review, we examine the pathophysiologic construct contributing to adverse prognosis of MVD in STEMI, relevant available evidence that currently guides the management of the noninfarct-related artery (IRA) stenosis and define the remaining knowledge gaps for future studies.

RECENT FINDINGS

Results of recent small sized randomized trials, when pooled, suggest improvement in CV outcomes including CV mortality and repeat revascularization with revascularization of the non-IRA stenosis compared with medical management alone. In addition, there does not appear to be an increase in bleeding, contrast-induced nephropathy or stroke, as suggested by earlier observational data.

SUMMARY

These recent data have led to a Class IIb recommendation in the American College of Cardiology/American Heart Association guidelines stating that non-IRA revascularization may be considered in selected patients with STEMI and MVD who are hemodynamically stable, either at the time of primary PCI or as a planned staged procedure. The ongoing COMPLETE and CULPRIT-SHOCK studies will provide additional data to further inform the role of non-IRA revascularization and its timing in the management of these patients.

MH, Zarich SW, Osho AA, Gluud C, Kelbæk H, Engstrøm T, Høfsten DE, Brennan JM. Complete versus culprit-only revascularisation in ST elevation myocardial infarction with multi-vessel disease

BACKGROUND

Multi-vessel coronary disease in people with ST elevation myocardial infarction (STEMI) is common and is associated with worse prognosis after STEMI. Based on limited evidence, international guidelines recommend intervention on only the culprit vessel during STEMI. This, in turn, leaves other significantly stenosed coronary arteries for medical therapy or revascularisation based on inducible ischaemia on provocative testing. Newer data suggest that intervention on both the culprit and non-culprit stenotic coronary arteries (complete intervention) may yield better results compared with culprit-only intervention.

OBJECTIVES

To assess the effects of early complete revascularisation compared with culprit vessel only intervention strategy in people with STEMI and multi-vessel coronary disease.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, World Health Organization International Clinical Trials Registry Platform Search Portal, and ClinicalTrials.gov. The date of the last search was 4 January 2017. We applied no language restrictions. We handsearched conference proceedings to December 2016, and contacted authors and companies related to the field.

SELECTION CRITERIA

We included only randomised controlled trials (RCTs), wherein complete revascularisation strategy was compared with a culprit-only percutaneous coronary intervention (PCI) for the treatment of people with STEMI and multi-vessel coronary disease.

DATA COLLECTION AND ANALYSIS

We assessed the methodological quality of each trial using the Cochrane 'Risk of bias' tool. We resolved the disagreements by discussion among review authors. We followed standard methodological approaches recommended by Cochrane. The primary outcomes were long-term (one year or greater after the index intervention) all-cause mortality, long-term cardiovascular mortality, long-term non-fatal myocardial infarction, and adverse events. The secondary outcomes were short-term (within the first 30 days after the index intervention) all-cause mortality, short-term cardiovascular mortality, short-term non-fatal myocardial infarction, revascularisation, health-related quality of life, and cost. We analysed data using fixed-effect models, and expressed results as risk ratios (RR) with 95% confidence intervals (CI). We used GRADE criteria to assess the quality of evidence and we conducted Trial Sequential Analysis (TSA) to control risks of random errors.

MAIN RESULTS

We included nine RCTs, that involved 2633 people with STEMI and multi-vessel coronary disease randomly assigned to either a complete (n = 1381) versus culprit-only (n = 1252) revascularisation strategy. The complete and the culprit-only revascularisation strategies did not differ for long-term all-cause mortality (65/1274 (5.1%) in complete group versus 72/1143 (6.3%) in culprit-only group; RR 0.80, 95% CI 0.58 to 1.11; participants = 2417; studies = 8; I2 = 0%; very low quality evidence). Compared with culprit-only intervention, the complete revascularisation strategy was associated with a lower proportion of long-term cardiovascular mortality (28/1143 (2.4%) in complete group versus 51/1086 (4.7%) in culprit-only group; RR 0.50, 95% CI 0.32 to 0.79; participants = 2229; studies = 6; I2 = 0%; very low quality evidence) and long-term non-fatal myocardial infarction (47/1095 (4.3%) in complete group versus 70/1004 (7.0%) in culprit-only group; RR 0.62, 95% CI 0.44 to 0.89; participants = 2099; studies = 6; I2 = 0%; very low quality evidence). The complete and the culprit-only revascularisation strategies did not differ in combined adverse events (51/2096 (2.4%) in complete group versus 57/1990 (2.9%) in culprit-only group; RR 0.84, 95% CI 0.58 to 1.21; participants = 4086; I2 = 0%; very low quality evidence). Complete revascularisation was associated with lower proportion of long-term revascularisation (145/1374 (10.6%) in complete group versus 258/1242 (20.8%) in culprit-only group; RR 0.47, 95% CI 0.39 to 0.57; participants = 2616; studies = 9; I2 = 31%; very low quality evidence). TSA of long-term all-cause mortality, long-term cardiovascular mortality, and long-term non-fatal myocardial infarction showed that more RCTs are needed to reach more conclusive results on these outcomes. Regarding long-term repeat revascularisation more RCTs may not change our present result. The quality of the evidence was judged to be very low for all primary and the majority of the secondary outcomes mainly due to risk of bias, imprecision, and indirectness.

AUTHORS' CONCLUSIONS

Compared with culprit-only intervention, the complete revascularisation strategy may be superior due to lower proportions of long-term cardiovascular mortality, long-term revascularisation, and long-term non-fatal myocardial infarction, but these findings are based on evidence of very low quality. TSA also supports the need for more RCTs in order to draw stronger conclusions regarding the effects of complete revascularisation on long-term all-cause mortality, long-term cardiovascular mortality, and long-term non-fatal myocardial infarction.

Meta-Analysis of Randomized Controlled Trials Comparing Multivessel Versus Culprit-Only Revascularization for Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Disease Undergoing Primary Percutaneous Coronary Intervention

Current guidelines recommend against revascularization of the noninfarct artery during the index percutaneous coronary intervention (PCI) in hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI). This was based largely on observational studies with few data coming from randomized controlled trials (RCTs). Recently, several small-to-moderate sized RCTs have provided data, suggesting that a multivessel revascularization approach may be appropriate. We performed a meta-analysis of RCTs comparing multivessel percutaneous coronary intervention (MV PCI) versus culprit vessel-only revascularization (COR) during primary PCI in patients with STEMI and multivessel coronary disease (MVCD). We searched Medline, PubMed, and Scopus databases for RCTs comparing MV PCI versus COR in patients with STEMI and MVCD. The incidence of all-cause death, cardiac death, recurrent myocardial infarction, and revascularization during follow-up were extracted. Four RCTs fit our primary selection criteria. Among these, 566 patients underwent MV PCI (either at the time of the primary PCI or as a staged procedure) and 478 patients underwent COR. During long-term follow-up (range 1 to 2.5 years), combined data indicated a significant reduction in all-cause mortality (relative risk [RR] 0.57, 95% confidence interval [CI] 0.36 to 0.92, p = 0.02) and in cardiac death (RR 0.38, 95% CI 0.20 to 0.73, p = 0.004) with MV PCI. In addition, there was a significantly lower risk of recurrent myocardial infarction (RR 0.41, 95% CI 0.23 to 0.75; p = 0.004) and future revascularization (RR 0.37, 95% CI 0.27 to 0.52; p <0.00001). In conclusion, from the RCT data, MV PCI appears to improve outcomes in patients with STEMI and MVCD.