Optimal Timing of Complete Revascularization in Acute Coronary Syndrome: A Systematic Review and Meta-Analysis

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.

Keywords: acute coronary syndrome; complete revascularization; meta‐analysis; percutaneous coronary intervention; single‐stage revascularization; staged revascularization.

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta‐Analyses flow diagram. CR indicates culprit‐only revascularization; SR, staged revascularization.

Figure 2

Forest plots of the relative risks of adverse cardiovascular events at 6 months from randomized controlled trials comparing single‐stage with multistage complete revascularization. MACE indicates major adverse cardiovascular event; MI, myocardial infarction; PRIMA, the Primary Percutaneous Intervention for Acute Myocardial Infarction trial; RR, risk ratio; SMILE, Impact of Different Treatment in Multivessel Non ST Elevation Myocardial Infarction Patients: One Stage Versus Multistaged Percutaneous Coronary Intervention trial.

Figure 3

Forest plots of the relative risks of adverse cardiovascular events at longest follow‐up from randomized controlled trials comparing single‐stage with multistage complete revascularization. MACE indicates major adverse cardiovascular event; MI, myocardial infarction; PRIMA, the Primary Percutaneous Intervention for Acute Myocardial Infarction trial; RR, risk ratio; SMILE, Impact of Different Treatment in Multivessel Non ST Elevation Myocardial Infarction Patients: One Stage Versus Multistaged Percutaneous Coronary Intervention trial.