Kevin R Bainey1, Thomas Engstrøm2, Pieter C Smits3, Anthony H Gershlick4, Stefan K James5, Robert F Storey6, David A Wood7, Roxana Mehran8, John A Cairns9, Shamir R Mehta10. 1. Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada. 2. The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark. 3. Department of Cardiology, Maasstad Ziekenhuis, Rotterdam, the Netherlands. 4. Department of Cardiovascular Sciences, University of Leicester and NIHR (National Institute of Heath Research) Leicester Cardiovascular Biomedical Research Unit, University Hospitals of Leicester NHS (National Health Service) Trust, Glenfield Hospital, Leicester, United Kingdom. 5. Department of Medical Sciences, Uppsala University, Uppsala, Sweden. 6. Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom. 7. Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada. 8. Zena and Michael A. Weiner Cardiovascular Institute, Mount Sinai School of Medicine, New York, New York. 9. Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada. 10. Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada.
Abstract
Importance: Recently, the Complete vs Culprit-Only Revascularization to Treat Multivessel Disease After Early PCI (percutaneous coronary intervention) for STEMI (ST-segment elevation myocardial infarction [MI]) (COMPLETE) trial showed that angiography-guided PCI of the nonculprit lesion with the goal of complete revascularization reduced cardiovascular (CV) death or new MI compared with PCI of the culprit lesion only in STEMI. Whether complete revascularization also reduces CV mortality is uncertain. Moreover, whether the association of complete revascularization with hard clinical outcomes is consistent when fractional flow reserve (FFR)- and angiography-guided strategies are used is unknown. Objective: To determine through a systematic review and meta-analysis (1) whether complete revascularization is associated with decreased CV mortality and (2) whether heterogeneity in the association occurs when FFR- and angiography-guided PCI strategies for nonculprit lesions are performed. Data Sources: A systematic search of MEDLINE, Embase, ISI Web of Science, and CENTRAL (Cochrane Central Register of Controlled Trials) from database inception to September 30, 2019, was performed. Conference proceedings were also reviewed from January 1, 2002, to September 30, 2019. Study Selection: English-language randomized clinical trials comparing complete revascularization vs culprit-lesion-only PCI in patients with STEMI and multivessel disease were included. Data Extraction and Synthesis: The combined odds ratio (OR) was calculated with the random-effects model using the Mantel-Haenszel method (sensitivity with fixed-effects model). Heterogeneity was measured using the I2 statistic. Publication bias was evaluated using the inverted funnel plot approach. Data were analyzed from October 2019 to January 2020. Main Outcomes and Measures: Cardiovascular death and the composite of CV death or new MI. Results: Ten randomized clinical trials involving 7030 unique patients were included. The weighted mean follow-up time was 29.5 months. Complete revascularization was associated with reduced CV death compared with culprit-lesion-only PCI (80 of 3191 [2.5%] vs 106 of 3406 [3.1%]; OR, 0.69 [95% CI, 0.48-0.99]; P = .05; fixed-effects model OR, 0.74 [95% CI, 0.55-0.99]; P = .04). All-cause mortality occurred in 153 of 3426 patients (4.5%) in the complete revascularization group vs 177 of 3604 (4.9%) in the culprit-lesion-only group (OR, 0.84 [95% CI, 0.67-1.05]; P = .13; I2 = 0%). Complete revascularization was associated with a reduced composite of CV death or new MI (192 of 2616 [7.3%] vs 266 of 2586 [10.3%]; OR, 0.69 [95% CI, 0.55-0.87]; P = .001; fixed-effects model OR, 0.69 [95% CI, 0.57-0.84]; P < .001), with no heterogeneity in this outcome when complete revascularization was performed using an FFR-guided strategy (OR, 0.78 [95% CI, 0.43-1.44]) or an angiography-guided strategy (OR, 0.61 [95% CI, 0.38-0.97]; P = .52 for interaction). Conclusions and Relevance: In patients with STEMI and multivessel disease, complete revascularization was associated with a reduction in CV mortality compared with culprit-lesion-only PCI. There was no differential association with treatment between FFR- and angiography-guided strategies on major CV outcomes.
Importance: Recently, the Complete vs Culprit-Only Revascularization to Treat Multivessel Disease After Early PCI (percutaneous coronary intervention) for STEMI (ST-segment elevation myocardial infarction [MI]) (COMPLETE) trial showed that angiography-guided PCI of the nonculprit lesion with the goal of complete revascularization reduced cardiovascular (CV) death or new MI compared with PCI of the culprit lesion only in STEMI. Whether complete revascularization also reduces CV mortality is uncertain. Moreover, whether the association of complete revascularization with hard clinical outcomes is consistent when fractional flow reserve (FFR)- and angiography-guided strategies are used is unknown. Objective: To determine through a systematic review and meta-analysis (1) whether complete revascularization is associated with decreased CV mortality and (2) whether heterogeneity in the association occurs when FFR- and angiography-guided PCI strategies for nonculprit lesions are performed. Data Sources: A systematic search of MEDLINE, Embase, ISI Web of Science, and CENTRAL (Cochrane Central Register of Controlled Trials) from database inception to September 30, 2019, was performed. Conference proceedings were also reviewed from January 1, 2002, to September 30, 2019. Study Selection: English-language randomized clinical trials comparing complete revascularization vs culprit-lesion-only PCI in patients with STEMI and multivessel disease were included. Data Extraction and Synthesis: The combined odds ratio (OR) was calculated with the random-effects model using the Mantel-Haenszel method (sensitivity with fixed-effects model). Heterogeneity was measured using the I2 statistic. Publication bias was evaluated using the inverted funnel plot approach. Data were analyzed from October 2019 to January 2020. Main Outcomes and Measures: Cardiovascular death and the composite of CV death or new MI. Results: Ten randomized clinical trials involving 7030 unique patients were included. The weighted mean follow-up time was 29.5 months. Complete revascularization was associated with reduced CV death compared with culprit-lesion-only PCI (80 of 3191 [2.5%] vs 106 of 3406 [3.1%]; OR, 0.69 [95% CI, 0.48-0.99]; P = .05; fixed-effects model OR, 0.74 [95% CI, 0.55-0.99]; P = .04). All-cause mortality occurred in 153 of 3426 patients (4.5%) in the complete revascularization group vs 177 of 3604 (4.9%) in the culprit-lesion-only group (OR, 0.84 [95% CI, 0.67-1.05]; P = .13; I2 = 0%). Complete revascularization was associated with a reduced composite of CV death or new MI (192 of 2616 [7.3%] vs 266 of 2586 [10.3%]; OR, 0.69 [95% CI, 0.55-0.87]; P = .001; fixed-effects model OR, 0.69 [95% CI, 0.57-0.84]; P < .001), with no heterogeneity in this outcome when complete revascularization was performed using an FFR-guided strategy (OR, 0.78 [95% CI, 0.43-1.44]) or an angiography-guided strategy (OR, 0.61 [95% CI, 0.38-0.97]; P = .52 for interaction). Conclusions and Relevance: In patients with STEMI and multivessel disease, complete revascularization was associated with a reduction in CV mortality compared with culprit-lesion-only PCI. There was no differential association with treatment between FFR- and angiography-guided strategies on major CV outcomes.
Authors: Roberto C Cerrud-Rodriguez; Syed Muhammad Ibrahim Rashid; Karlo A Wiley; Maday Gonzalez; Valeriia A Kosmacheva; Isabella Castillero-Norato; Cornelia Rivera; Pedro Villablanca; Jose Wiley Journal: Int J Gen Med Date: 2021-06-03
Authors: Krishnaraj Sinhji Rathod; Marco Spagnolo; Mark K Elliott; Anne-Marie Beirne; Elliot J Smith; Rajiv Amersey; Charles Knight; Roshan Weerackody; Andreas Baumbach; Anthony Mathur; Daniel A Jones Journal: Clin Med Insights Cardiol Date: 2020-08-21
Authors: Jan-Quinten Mol; Anouar Belkacemi; Rick Hja Volleberg; Martijn Meuwissen; Alexey V Protopopov; Peep Laanmets; Oleg V Krestyaninov; Robert Dennert; Rohit M Oemrawsingh; Jan-Peter van Kuijk; Karin Arkenbout; Dirk J van der Heijden; Saman Rasoul; Erik Lipsic; Steven Teerenstra; Cyril Camaro; Peter Damman; Maarten Ah van Leeuwen; Robert-Jan van Geuns; Niels van Royen Journal: BMJ Open Date: 2021-07-07 Impact factor: 2.692