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Akbari T, Al-Lamee R. Percutaneous coronary intervention in multi-vessel disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 44:80-91. [DOI: 10.1016/j.carrev.2022.06.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 01/09/2023]
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Gupta K, Chopra L, Salame A, Gharpure N, Prejean SP, von Mering G, Al Solaiman F, Eudailey K, Bajaj NS, Ahmed MI. Complete versus culprit-vessel only revascularization in STEMI: An updated meta-analysis of randomized control trials. IJC HEART & VASCULATURE 2020; 27:100481. [PMID: 32373708 PMCID: PMC7191581 DOI: 10.1016/j.ijcha.2020.100481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/21/2020] [Accepted: 02/02/2020] [Indexed: 11/21/2022]
Affiliation(s)
- Kartik Gupta
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lakshay Chopra
- All India Institute of Medical Sciences, New Delhi, India
| | - Ameen Salame
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nitin Gharpure
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Shane P Prejean
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Gregory von Mering
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Firas Al Solaiman
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kyle Eudailey
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Navkaranbir S Bajaj
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA.,Section of Cardiology, Birmingham Veterans Affair Medical Center, Birmingham, AL, USA.,Division of Molecular Imaging and Therapeutics, Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mustafa I Ahmed
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
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Gupta A, Bajaj NS, Arora P, Arora G, Qamar A, Bhatt DL. FFR-guided multivessel stenting reduces urgent revascularization compared with infarct-related artery only stenting in ST-elevation myocardial infarction: A meta-analysis of randomized controlled trials. Int J Cardiol 2018; 252:63-67. [PMID: 29249439 DOI: 10.1016/j.ijcard.2017.07.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 06/02/2017] [Accepted: 07/12/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Randomized controlled trials (RCTs) have shown fractional flow reserve-guided (FFR) multivessel stenting to be superior to infarct-related artery (IRA) only stenting in patients with ST-elevation myocardial infarction (STEMI) and multivessel disease. This effect was mainly driven by a reduction in overall repeat revascularization. However, the ability to assess the effect of this strategy on urgent revascularization or reinfarction was underpowered in individual trials. METHODS We searched Pubmed, EMBASE, Cochrane CENTRAL, and Web of Science for RCTs of FFR-guided multivessel stenting versus IRA-only stenting in STEMI with multivessel disease. The outcomes of interest were death, reinfarction, urgent, and non-urgent repeat revascularization. Risk ratios (RR) were pooled using the DerSimonian and Laird random-effects model. RESULTS After review of 786 citations, 2 RCTs were included. The pooled results demonstrated a significant reduction in the composite of death, reinfarction, or revascularization in the FFR-guided multivessel stenting group versus IRA-only stenting group (RR [95%, Confidence Interval]: 0.49 [0.33-0.72], p<0.001). This risk reduction was driven mainly by a reduction in repeat revascularization, both urgent (0.41 [0.24-0.71], p=0.002) and non-urgent revascularization (0.31 [0.19-0.50], p<0.001). Pooled RR for reinfarction was lower in the FFR-guided strategy, but was not statistically significant (0.71[0.39-1.31], p=0.28). CONCLUSIONS This systematic review and meta-analysis suggests that a strategy of FFR-guided multivessel stenting in STEMI patients reduces not only overall repeat revascularization but also urgent revascularization. The effect on reinfarction needs to be evaluated in larger trials.
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Affiliation(s)
- Ankur Gupta
- Heart and Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Navkaranbir S Bajaj
- Heart and Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pankaj Arora
- Division of Cardiovascular Disease, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA; Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Garima Arora
- Division of Cardiovascular Disease, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Arman Qamar
- Heart and Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Deepak L Bhatt
- Heart and Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Complete Versus Culprit-Only Revascularization in STEMI: a Contemporary Review. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:41. [PMID: 29627944 DOI: 10.1007/s11936-018-0636-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
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.
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Nguyen AV, Thanh LV, Kamel MG, Abdelrahman SAM, EL-Mekawy M, Mokhtar MA, Ali AA, Hoang NNN, Vuong NL, Abd-Elhay FAE, Omer OA, Mohamed AA, Hirayama K, Huy NT. Optimal percutaneous coronary intervention in patients with ST-elevation myocardial infarction and multivessel disease: An updated, large-scale systematic review and meta-analysis. Int J Cardiol 2017. [DOI: 10.1016/j.ijcard.2017.06.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Andries G, Khera S, Timmermans RJ, Aronow WS. Complete versus culprit only revascularization in ST-elevation myocardial infarction-a perspective on recent trials and recommendations. J Thorac Dis 2017; 9:2159-2167. [PMID: 28840017 DOI: 10.21037/jtd.2017.06.95] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The presence of multivessel coronary artery disease (CAD) is strongly associated with higher 30-day mortality, reduced myocardial reperfusion success, reinfarction, and occurrence of major adverse cardiac events (MACE) at 1 year compared with single-vessel CAD. Despite higher morbidity and mortality in patients with ST-elevation myocardial infarction (STEMI) and coexistent multivessel CAD, major guidelines recommended against percutaneous coronary intervention (PCI) on non-culprit lesions at the time of primary PCI in patients with STEMI who are hemodynamically stable. The presence of multivessel CAD often poses a therapeutic dilemma for interventional cardiologists. A few larger scale randomized controlled trials (RCTs) and meta-analyses have been conducted. The conclusions regarding multivessel PCI generally trend towards lower risk of MACE, repeat revascularization, with similar risks of recurrent myocardial infarction (MI) and mortality. However, none of the RCTs were adequately powered for hard outcomes of death and MI.
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Affiliation(s)
- Gabriela Andries
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Sahil Khera
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA.,Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Robert J Timmermans
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Wilbert S Aronow
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
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Patel S, Bailey SR. Revascularization Strategies in STEMI with Multivessel Disease: Deciding on Culprit Versus Complete-Ad Hoc or Staged. Curr Cardiol Rep 2017; 19:93. [PMID: 28840487 DOI: 10.1007/s11886-017-0906-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW This review will address the clinical conundrum of those who may derive clinical benefit from complete revascularization of coronary stenosis that are discovered at the time of ST segment elevation myocardial infarction (STEMI). The decision to revascularize additional vessels with angiographic stenosis beyond the culprit lesion remains controversial, as does the timing of revascularization. RECENT FINDINGS STEMI patients represent a high-risk patient population that have up to a 50% prevalence of multivessel disease. Multivessel disease represents an important risk factor for short- and long-term morbidity and mortality. Potential benefits of multivessel PCI for STEMI might include reduced short- and long-term mortality, revascularization, reduced resource utilization, and costs. Which population will benefit and what the optimal timing of revascularization in the peri-MI period remains controversial. Consideration of multivessel revascularization in the setting of STEMI may occur in up to one half of STEMI patients. Evaluation of the comorbidities including diabetes, extent of myocardium at risk, lesion complexity, ventricular function, and risk factors for complications such as contrast induced nephropathy which is important in determining the appropriate care pathway.
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Affiliation(s)
- Shalin Patel
- From the Janey Briscoe Center of Excellence for Cardiovascular Research, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78232, USA
| | - Steven R Bailey
- From the Janey Briscoe Center of Excellence for Cardiovascular Research, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78232, USA.
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Vogel B, Mehta SR, Mehran R. Reperfusion strategies in acute myocardial infarction and multivessel disease. Nat Rev Cardiol 2017; 14:665-678. [DOI: 10.1038/nrcardio.2017.88] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Gaffar R, Habib B, Filion KB, Reynier P, Eisenberg MJ. Optimal Timing of Complete Revascularization in Acute Coronary Syndrome: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2017; 6:JAHA.116.005381. [PMID: 28396570 PMCID: PMC5533029 DOI: 10.1161/jaha.116.005381] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Studies have suggested that complete revascularization is superior to culprit‐only revascularization for the treatment of enzyme‐positive acute coronary syndrome. However, the optimal timing of complete revascularization remains unclear. We conducted a systematic review and meta‐analysis of randomized controlled trials comparing single‐stage complete revascularization with multistage percutaneous coronary intervention in patients with ST‐segment elevation myocardial infarction or non–ST‐segment elevation myocardial infarction with multivessel disease. Methods and Results We systematically searched the Cochrane Central Register of Controlled Trials, Embase, PubMed, and MEDLINE for randomized controlled trials comparing single‐stage complete revascularization with multistage revascularization in patients with enzyme‐positive acute coronary syndrome. The primary outcome was the incidence of major adverse cardiovascular events at longest follow‐up. Data were pooled using DerSimonian and Laird random‐effects models. Four randomized controlled trials (n=838) were included in our meta‐analysis. The risk of unplanned repeat revascularization at longest follow‐up was significantly lower in patients randomized to single‐stage complete revascularization (risk ratio, 0.68; 95% CI, 0.47–0.99). Results also suggest a trend towards lower risks of major adverse cardiovascular events for patients randomized to single‐stage revascularization at 6 months (risk ratio, 0.67; 95% CI, 0.40–1.11) and at longest follow‐up (risk ratio, 0.79; 95% CI, 0.52–1.20). Risks of mortality and recurrent myocardial infarction at longest follow‐up were also lower with single‐stage revascularization, but 95% CIs were wide and included unity. Conclusions Our results suggest that single‐stage complete revascularization is safe. There also appears to be a trend towards lower long‐term risks of mortality and major adverse cardiovascular events; however, additional randomized controlled trials are required to confirm the potential benefits of single‐stage multivessel percutaneous coronary intervention.
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Affiliation(s)
- Rouan Gaffar
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Bettina Habib
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Kristian B Filion
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Departments of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Pauline Reynier
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Mark J Eisenberg
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada .,Division of Cardiology, Jewish General Hospital, Montreal, Quebec, Canada.,Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Departments of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
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Kalra R, Arora P, Morgan C, Hage FG, Iskandrian AE, Bajaj NS. Conducting and interpreting high-quality systematic reviews and meta-analyses. J Nucl Cardiol 2017; 24:471-481. [PMID: 27484213 DOI: 10.1007/s12350-016-0598-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 04/13/2016] [Indexed: 11/27/2022]
Abstract
Systematic reviews and meta-analyses are powerful tools for summarizing existing literature and combining evidence from multiple studies. These methods employ complex searches, statistical techniques, and presentation techniques with which the clinical audience may not be very familiar. This review article aims to familiarize the clinical audience with the various techniques employed to conduct a high-quality systematic review and meta-analysis.
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Affiliation(s)
- Rajat Kalra
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Pankaj Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham, BDB D-201, 1808 7th Avenue South, Birmingham, AL, 35294-0012, USA
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Charity Morgan
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Fadi G Hage
- Division of Cardiovascular Disease, University of Alabama at Birmingham, BDB D-201, 1808 7th Avenue South, Birmingham, AL, 35294-0012, USA
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Ami E Iskandrian
- Division of Cardiovascular Disease, University of Alabama at Birmingham, BDB D-201, 1808 7th Avenue South, Birmingham, AL, 35294-0012, USA
| | - Navkaranbir S Bajaj
- Division of Cardiovascular Disease, University of Alabama at Birmingham, BDB D-201, 1808 7th Avenue South, Birmingham, AL, 35294-0012, USA.
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.
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Complete or Culprit-Only Revascularization for Patients With Multivessel Coronary Artery Disease Undergoing Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2017; 10:315-324. [DOI: 10.1016/j.jcin.2016.11.047] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 11/22/2016] [Accepted: 11/30/2016] [Indexed: 01/24/2023]
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12
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Clinical values of left ventricular mechanical dyssynchrony assessment by gated myocardial perfusion SPECT in patients with acute myocardial infarction and multivessel disease. Eur J Nucl Med Mol Imaging 2016; 44:259-266. [DOI: 10.1007/s00259-016-3542-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 09/29/2016] [Indexed: 10/20/2022]
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Bates ER, Tamis-Holland JE, Bittl JA, O’Gara PT, Levine GN. PCI Strategies in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Artery Disease. J Am Coll Cardiol 2016; 68:1066-81. [DOI: 10.1016/j.jacc.2016.05.086] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/19/2016] [Accepted: 05/10/2016] [Indexed: 12/19/2022]
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