Islam Y Elgendy1, Ahmed N Mahmoud2, Dharam J Kumbhani3, Deepak L Bhatt4, Anthony A Bavry5. 1. Department of Medicine, University of Florida, Gainesville, Florida. Electronic address: islam.elgendy@medicine.ufl.edu. 2. Department of Medicine, University of Florida, Gainesville, Florida. 3. Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas. 4. Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts. 5. Department of Medicine, University of Florida, Gainesville, Florida; North Florida/South Georgia Veterans Health Systems, Gainesville, Florida.
Abstract
OBJECTIVES: The authors sought to compare the effectiveness of the different revascularization strategies in ST-segment elevation myocardial infarction (STEMI) patients with multivessel coronary artery disease undergoing primary percutaneous coronary intervention (PCI). BACKGROUND: Recent randomized trials have suggested that multivessel complete revascularization at the time of primary percutaneous coronary intervention (PCI) is associated with better outcomes, however; the optimum timing for nonculprit PCI is unknown. METHODS: Trials that randomized STEMI patients with multivessel disease to any combination of the 4 different revascularization strategies (i.e., complete revascularization at the index procedure, staged procedure during the hospitalization, staged procedure after discharge or culprit-only revascularization) were included. Random effect risk ratios (RRs) were conducted. Network meta-analysis was constructed using mixed treatment comparison models, and the 4 revascularization strategies were compared. RESULTS: A total of 10 trials with 2,285 patients were included. In the pairwise meta-analysis, complete revascularization (i.e., at the index procedure or as a staged procedure) was associated with a lower risk of major adverse cardiac events (MACE) (RR: 0.57; 95% confidence interval [CI]: 0.42 to 0.77), due to lower risk of urgent revascularization (RR: 0.44; 95% CI: 0.30 to 0.66). The risk of all-cause mortality (RR: 0.76; 95% CI: 0.52 to 1.12), and spontaneous reinfarction (RR: 0.54; 95% CI: 0.23 to 1.27) was similar. The reduction in the risk of MACE was observed irrespective of the timing of nonculprit artery revascularization in the mixed treatment model. CONCLUSIONS: Current evidence from randomized trials suggests that the risk of all-cause mortality and spontaneous reinfarction is not different among the various revascularization strategies for multivessel disease. Complete revascularization at the index procedure or as a staged procedure (either during the hospitalization or after discharge) was associated with a reduction of MACE due to reduction in urgent revascularization with no difference between these 3 strategies. Future trials are needed to determine the impact of complete revascularization on the risk of all-cause mortality and spontaneous reinfarction. Copyright Â
OBJECTIVES: The authors sought to compare the effectiveness of the different revascularization strategies in ST-segment elevation myocardial infarction (STEMI) patients with multivessel coronary artery disease undergoing primary percutaneous coronary intervention (PCI). BACKGROUND: Recent randomized trials have suggested that multivessel complete revascularization at the time of primary percutaneous coronary intervention (PCI) is associated with better outcomes, however; the optimum timing for nonculprit PCI is unknown. METHODS: Trials that randomized STEMI patients with multivessel disease to any combination of the 4 different revascularization strategies (i.e., complete revascularization at the index procedure, staged procedure during the hospitalization, staged procedure after discharge or culprit-only revascularization) were included. Random effect risk ratios (RRs) were conducted. Network meta-analysis was constructed using mixed treatment comparison models, and the 4 revascularization strategies were compared. RESULTS: A total of 10 trials with 2,285 patients were included. In the pairwise meta-analysis, complete revascularization (i.e., at the index procedure or as a staged procedure) was associated with a lower risk of major adverse cardiac events (MACE) (RR: 0.57; 95% confidence interval [CI]: 0.42 to 0.77), due to lower risk of urgent revascularization (RR: 0.44; 95% CI: 0.30 to 0.66). The risk of all-cause mortality (RR: 0.76; 95% CI: 0.52 to 1.12), and spontaneous reinfarction (RR: 0.54; 95% CI: 0.23 to 1.27) was similar. The reduction in the risk of MACE was observed irrespective of the timing of nonculprit artery revascularization in the mixed treatment model. CONCLUSIONS: Current evidence from randomized trials suggests that the risk of all-cause mortality and spontaneous reinfarction is not different among the various revascularization strategies for multivessel disease. Complete revascularization at the index procedure or as a staged procedure (either during the hospitalization or after discharge) was associated with a reduction of MACE due to reduction in urgent revascularization with no difference between these 3 strategies. Future trials are needed to determine the impact of complete revascularization on the risk of all-cause mortality and spontaneous reinfarction. Copyright Â
Authors: Mohammed Osman; Safi U Khan; Peter D Farjo; Noor Chima; Babikir Kheiri; Firas Zahr; Mohamad Alkhouli Journal: Am J Cardiol Date: 2019-11-19 Impact factor: 2.778