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Feng Y, Li S, Hu S, Wan J, Shao H. 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. Front Cardiovasc Med 2022; 9:1000664. [PMID: 36225962 PMCID: PMC9548605 DOI: 10.3389/fcvm.2022.1000664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
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.
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Affiliation(s)
- Yujia Feng
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Shu Li
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Sihan Hu
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jing Wan
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China
- *Correspondence: Jing Wan
| | - Hua Shao
- Department of Clinical Laboratory, Remin Hospital of Wuhan University, Wuhan, China
- Hua Shao
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Sun D, Li W, Zhang H, Li Y, Zhang Q. Inverted U-shaped relationship between body mass index and multivessel lesions in Chinese patients with myocardial infarction: a cross-sectional study. J Int Med Res 2021; 48:300060520932820. [PMID: 32692271 PMCID: PMC7375727 DOI: 10.1177/0300060520932820] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE To investigate the association of body mass index (BMI) with multivessel coronary artery disease in patients with myocardial infarction. METHODS This study was performed in 1566 patients with myocardial infarction in the Department of Cardiology, Affiliated Hospital of Jining Medical University, China. Independent and dependent variables were BMI measured at baseline and multivessel coronary artery disease, respectively. The covariates examined in this study were age, systolic blood pressure, diastolic blood pressure, heart rate, creatinine, uric acid, bilirubin, cholesterol, triacylglycerol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, left ventricular ejection fraction, sex, heart failure, atrial fibrillation, chronic obstructive pulmonary disease, stroke, hypertension, diabetes mellitus, and smoking. RESULTS A nonlinear relationship was detected between BMI and multivessel coronary artery disease, and this was an inverted U-shaped curve and the cutoff point was 26.3 kg/m2. The effect sizes and confidence intervals on the left and right sides of the inflection point were 1.10 (1.01-1.20) and 0.85 (0.74-0.97), respectively. CONCLUSIONS There is an obesity paradox for BMI > 26.3 kg/m2. Future studies should examine the relationship between BMI and prognosis in patients with myocardial infarction, which may be important for improving the prognosis through control of BMI.
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Affiliation(s)
| | | | | | | | - Qingyun Zhang
- Qingyun Zhang, Department of Cardiology, Affiliated Hospital of Jining Medical University, No. 79 Guhuai Road, Jining, Shandong, 272000, China.
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Bajraktari G, Bytyçi I, Henein MY, Alfonso F, Ahmed A, Jashari H, Bhatt DL. Complete revascularization for patients with multivessel coronary artery disease and ST-segment elevation myocardial infarction after the COMPLETE trial: A meta-analysis of randomized controlled trials. INTERNATIONAL JOURNAL OF CARDIOLOGY. HEART & VASCULATURE 2020; 29:100549. [PMID: 32577495 PMCID: PMC7301199 DOI: 10.1016/j.ijcha.2020.100549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/07/2020] [Accepted: 05/26/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The recently published COMPLETE trial has demonstrated that patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD), who underwent successful percutaneous coronary intervention (PCI) of both culprit and non-culprit (vs. culprit-only) lesions had a reduced risk of major adverse cardiac events (MACE), but not of cardiovascular or total mortality. The aim of this meta-analysis was to assess the efficacy of complete revascularization on cardiovascular or total mortality reduction using available randomized controlled trials (RCTs) including the COMPLETE trial, in hemodynamically stable STEMI patients with MVD. METHODS PubMed, MEDLINE, Embase, Scopus, Google Scholar, CENTRAL and ClinicalTrials.gov databases search identified 10 RCTs of 7033 patients with STEMI and MVD which compared complete (n = 3420) vs. only culprit lesion (n = 3613) PCI for a median 27.7 months follow-up. Random effect risk ratios were used to estimate for efficacy and safety outcomes. RESULTS Complete revascularization reduced the risk of MACE (10.4% vs.16.6%; RR = 0.59, 95% CI: 0.47 to 0.74, p < 0.0001), CV mortality (2.87% vs. 3.72%; RR = 0.73, 95% CI: 0.56 to 0.95, p = 0.02), reinfarction (5.1% vs. 7.1%; RR = 0.67, 95% CI: 0.52 to 0.86, p = 0.002), urgent revascularization (7.92% vs.17.4%; RR = 0.47, 95% CI: 0.30 to 0.73, p < 0.001), and CV hospitalization (8.68% vs.11.4%; RR = 0.65, 95% CI: 0.44to 0.96, p = 0.03) compared with culprit only revascularization. All-cause mortality, stroke, major bleeding events, or contrast induced nephropathy were not affected by the revascularization strategy. CONCLUSION The findings of this meta-analysis suggest that in patients with STEMI and MVD, complete revascularization is superior to culprit-only PCI in reducing the risk of MACE outcomes, including cardiovascular mortality, without increasing the risk of adverse safety outcomes.
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Affiliation(s)
- Gani Bajraktari
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- Clinic of Cardiology, University Clinical Centre of Kosovo, Prishtina, Kosovo
- University of Prishtina, Prishtina, Kosovo
| | - Ibadete Bytyçi
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- Clinic of Cardiology, University Clinical Centre of Kosovo, Prishtina, Kosovo
| | - Michael Y Henein
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Fernando Alfonso
- Cardiac Department, La Princesa University Hospital, Institute of Health Research, IIS-IP, CIBER-CV University Autónoma of Madrid, Madrid, Spain
| | - Ali Ahmed
- Veterans Affairs Medical Center, George Washington University, and Georgetown University, Washington, DC, USA
| | - Haki Jashari
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
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Osman M, Khan SU, Farjo PD, Chima N, Kheiri B, Zahr F, Alkhouli M. Meta-Analysis Comparing Complete Versus Infarct-Related Artery Revascularization in Patients With ST-Elevation Myocardial Infarction and Multivessel Coronary Disease. Am J Cardiol 2020; 125:513-520. [PMID: 31812228 DOI: 10.1016/j.amjcard.2019.11.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/09/2019] [Accepted: 11/13/2019] [Indexed: 01/09/2023]
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.
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Xu H, Zhang X, Li J, Liu H, Hu X, Yang J. Complete versus culprit-only revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease: a meta-analysis of randomized trials. BMC Cardiovasc Disord 2019; 19:91. [PMID: 31010423 PMCID: PMC6477715 DOI: 10.1186/s12872-019-1073-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 04/09/2019] [Indexed: 12/30/2022] Open
Abstract
Background The best strategy for the treatment of the non-infarct artery in patients with ST-elevation myocardial infarction (STEMI) and multivessel disease (MVD) undergoing primary percutaneous coronary intervention (PCI) is not yet defined. Methods We searched the literature for randomized controlled trials (RCTs) that compared complete revascularization (CR) with infarct-related coronary artery (IRA) only revascularization in hemodynamically stable patients with STEMI. Random effect risk ratios (RRs) were calculated for clinical outcomes. Results Nine RCTs with 2989 patients were included. No significant difference in all-cause mortality emerged between CR and IRA-only groups (relative risk [RR] = 0.74; 95% confidence interval [CI]: 0.52 to 1.04; p = 0.08). Compared with IRA-only, CR was associated with significantly lower rates of major adverse cardiac events (MACE) (RR = 0.53; 95% CI: 0.41 to 0.68; p < 0.001), cardiac death (RR = 0.48; 95% CI: 0.29 to 0.79; p = 0.004) and repeat revascularization (RR = 0.38; 95% CI: 0.30 to 0.47; p < 0.001). In subgroups analysis, immediate complete revascularization (ICR) reduced the risk of all-cause mortality (RR = 0.62; 95% CI: 0.39 to 0.97; p = 0.04), whereas staged complete revascularization (SCR) did not show any significant benefit in all-cause mortality (RR = 0.92; 95% CI: 0.46 to 1.86; p = 0.82). Stroke, contrast-induced nephropathy and major bleeding were not different between CR and IRA-only. Conclusions For patients with STEMI and multivessel disease undergoing primary PCI, complete revascularization did not decrease the risk of all-cause mortality in current evidence from randomized trials. When feasible, immediate complete revascularization might be considered in patients with STEMI and multivessel disease. Electronic supplementary material The online version of this article (10.1186/s12872-019-1073-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Haiyan Xu
- Department of Cardiology, The affiliated Huaian No.1 People's Hospital of Nanjing Medical University, 6 Beijing Road West, Huai'an, 223300, Jiangsu, China
| | - Xiwen Zhang
- Department of Cardiology, The affiliated Huaian No.1 People's Hospital of Nanjing Medical University, 6 Beijing Road West, Huai'an, 223300, Jiangsu, China
| | - Jiangjin Li
- Department of Cardiology, The affiliated Huaian No.1 People's Hospital of Nanjing Medical University, 6 Beijing Road West, Huai'an, 223300, Jiangsu, China
| | - Hailang Liu
- Department of Cardiology, The affiliated Huaian No.1 People's Hospital of Nanjing Medical University, 6 Beijing Road West, Huai'an, 223300, Jiangsu, China
| | - Xiao Hu
- Department of Cardiology, The affiliated Huaian No.1 People's Hospital of Nanjing Medical University, 6 Beijing Road West, Huai'an, 223300, Jiangsu, China
| | - Jing Yang
- Department of Cardiology, The affiliated Huaian No.1 People's Hospital of Nanjing Medical University, 6 Beijing Road West, Huai'an, 223300, Jiangsu, China.
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Fortuni F, Crimi G, Angelini F, Leonardi S, D'Ascenzo F, Ferlini M, Rolando M, Raisaro A, Oltrona Visconti L, Ferrario M, Gnecchi M, De Ferrari GM. Early Complete Revascularization in Hemodynamically Stable Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Disease. Can J Cardiol 2019; 35:1047-1057. [PMID: 31376906 DOI: 10.1016/j.cjca.2019.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/25/2019] [Accepted: 03/10/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The optimal strategy and timing of revascularization in hemodynamically stable patients with ST-segment elevation myocardial infarction and multivessel disease is unknown. We performed a systematic review and meta-analysis to explore the comparative efficacy and safety of early complete revascularization vs culprit-only or staged revascularization in this setting. METHODS We searched the literature for randomized clinical trials that assessed this issue. Early complete revascularization was defined as a complete revascularization achieved during the index procedure or within 72 hours. Efficacy outcomes were major adverse cardiovascular events, myocardial infarction, repeat revascularization, and all-cause mortality. Safety outcomes were all bleeding events, stroke, and contrast-induced acute kidney injury. RESULTS Nine randomized clinical trials with a total of 2837 patients were included; 1254 received early complete revascularization and 1583 were treated with other revascularization strategies. After a mean follow-up of 15.3 ± 9.4 months early complete revascularization was associated with a lower risk of major adverse cardiovascular events (relative risk [RR], 0.51; 95% confidence interval [CI], 0.41-0.62; P < 0.00001; number needed to treat = 8), myocardial infarction (RR, 0.59; 95% CI, 0.40-0.87), and repeat revascularization (RR, 0.39; 95% CI, 0.28-0.55) without any difference in all-cause mortality and in safety outcomes compared with culprit-only or staged revascularization. Moreover, fractional flow reserve-guided complete revascularization reduced the incidence of repeat revascularization compared with angiography-guided procedure (χ2 = 4.36; P = 0.04). CONCLUSIONS Early complete revascularization should be considered in hemodynamically stable patients with ST-segment elevation myocardial infarction and multivessel disease deemed suitable for percutaneous interventions. Fractional flow reserve-guided complete revascularization might be superior to angiography-guided procedures in reducing need for further interventions.
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Affiliation(s)
- Federico Fortuni
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Gabriele Crimi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Filippo Angelini
- Division of Cardiology, University of Torino, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Sergio Leonardi
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, University of Torino, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Marco Ferlini
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marco Rolando
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Arturo Raisaro
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Maurizio Ferrario
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Massimiliano Gnecchi
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Gaetano M De Ferrari
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, University of Pavia, Pavia, Italy
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