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Meta-Analysis
. 2020 Aug 1;5(8):881-888.
doi: 10.1001/jamacardio.2020.1251.

Complete vs Culprit-Lesion-Only Revascularization for ST-Segment Elevation Myocardial Infarction: A Systematic Review and Meta-analysis

Kevin R Bainey  1 , Thomas Engstrøm  2 , Pieter C Smits  3 , Anthony H Gershlick  4 , Stefan K James  5 , Robert F Storey  6 , David A Wood  7 , Roxana Mehran  8 , John A Cairns  9 , Shamir R Mehta  10
Affiliations
Meta-Analysis

Complete vs Culprit-Lesion-Only Revascularization for ST-Segment Elevation Myocardial Infarction: A Systematic Review and Meta-analysis

Kevin R Bainey et al. JAMA Cardiol. .

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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Bainey reported receiving grants and personal fees from AstraZeneca, Bayer AS, Boehringer Ingelheim, and Bristol-Myers Squibb/Pfizer, Inc, during the conduct of the study. Dr Engstrøm reported receiving personal fees from Bayer AS, Novo Nordisk A/S, Bristol-Myers Squibb, and Abbott Laboratories. Dr Smits reported receiving speaker and consultancy fees from Terumo Corporation and Abbott Vascular. Dr Gershlick reported receiving lecture fees and travel support from Abbott Vascular and grants from St. Jude Medical during the conduct of the study and grants and personal fees from Terumo Corporation and personal fees from AstraZeneca outside the submitted work. Dr James reported receiving grants from AstraZeneca, Janssen Pharmaceutica, Bayer AS, PhaseBio Pharmaceuticals, Inc, The Medicines Company, Medtronic plc, Boston Scientific, and Abbott Laboratories outside the submitted work. Dr Storey reported receiving grants and personal fees from PlaqueTec, AstraZeneca, GlyCardial Diagnostics, and Thromboserin Ltd and personal fees from Amgen, Inc, Bayer AS, Novartis International AG, Idorsia Ltd, Thromboserin Ltd, Haemonetics Corporation, GlyCardial Diagnostics, Bristol-Myers Squibb/Pfizer, Inc, Portola Pharmaceuticals, and Medscape outside the submitted work. Dr Wood reported receiving grants from the Canadian Institute of Health Research during the conduct of the study and consulting for Edwards Lifesciences and Medtronic plc and receiving research funding from Edwards Lifesciences, Boston Scientific, and Abbott Vascular outside the submitted work. Dr Mehran reported receiving grants and personal fees from Abbott Laboratories; grants from AstraZeneca, Bayer AS, Beth Israel Deaconess, CSL Behring, DSI, Medtronic plc, Novartis Pharmaceuticals, and OrbusNeich; grants from Bristol-Myers Squibb; personal fees from Boston Scientific, Janssen Scientific Affairs, Medscape/WebMD, Medtelligence (Janssen Scientific Affairs), Roivant Services, Sanofi SA, Siemens Medical Solutions USA, Inc, ACC, and the American Medical Association; nonfinancial support from Idorsia Pharmaceuticals Ltd and Regeneron Pharmaceuticals, Inc; from Abiomed, The Medicines Company, Spectranetics Corporation/Philips Healthcare/Volcano Corporation, Watermark Research Partners, Claret Medical, and Elixir Medical Corporation outside the submitted work; and having a spouse consulting for The Medicines Company and Abiomed. Dr Cairns reported receiving grants from Boston Scientific, AstraZeneca, and the Canadian Institute of Health Research during the conduct of the study and personal fees from Abbott Laboratories, Bayer, and Bristol-Myers Squibb/Pfizer, Inc, outside the submitted work. Dr Mehta reported receiving grants from AstraZeneca and Boston Scientific during the conduct of the study and grants from Sanofi SA outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Forest Plot of Long-term Cardiovascular Death in Patients With Complete Revascularization or Culprit-Lesion-Only Percutaneous Coronary Intervention (PCI)
Size of markers represents weight. Squares and diamonds indicate odds ratios (ORs); error bars, 95% CIs. COMPARE-ACUTE indicates Fractional Flow Reserve Guided Primary Multivessel Percutaneous Coronary Intervention to Improve Guideline Indexed Actual Standard of Care for Treatment of ST-Elevation Myocardial Infarction in Patients With Multivessel Coronary Disease; COMPLETE, Complete vs Culprit-Only Revascularization to Treat Multivessel Disease After Early PCI for STEMI; CvLPRIT, Complete vs Lesion-Only Primary PCI Trial; DANAMI-3–PRIMULTI, Primary PCI in Patients With ST-Elevation Myocardial Infarction and Multivessel Disease: Treatment of Culprit Lesion Only or Complete Revascularization; HELP AMI, Hepacoat for Culprit or Multivessel Stenting for Acute Myocardial Infarction; MH random, random-effects model using the Mantel-Haenszel method; and PRAMI, Preventive Angioplasty in Myocardial Infarction.
Figure 2.
Figure 2.. Forest Plot of Long-term Cardiovascular Death or New Myocardial Infarction in Patients With Complete Revascularization or Culprit-Lesion-Only Percutaneous Coronary Intervention (PCI)
Size of markers represents weight. Squares and diamonds indicate odds ratios (ORs); error bars, 95% CIs. COMPLETE indicates Complete vs Culprit-Only Revascularization to Treat Multivessel Disease After Early PCI for STEMI; DANAMI-3–PRIMULTI, Primary PCI in Patients With ST-Elevation Myocardial Infarction and Multivessel Disease: Treatment of Culprit Lesion Only or Complete Revascularization; HELP AMI, Hepacoat for Culprit or Multivessel Stenting for Acute Myocardial Infarction; MH random, random-effects model using the Mantel-Haenszel method; and PRAMI, Preventive Angioplasty in Myocardial Infarction.
Figure 3.
Figure 3.. Forest Plot of Long-term Cardiovascular Death or New Myocardial Infarction Stratified by Approach in Patients With Complete Revascularization or Culprit-Lesion-Only Percutaneous Coronary Intervention (PCI)
Patients were stratified by a fractional flow reserve (FRR)– vs angiography-guided nonculprit-lesion approach. Size of markers represents weight. Squares and diamonds indicate odds ratios (ORs); error bars, 95% CIs. COMPLETE, Complete vs Culprit-Only Revascularization to Treat Multivessel Disease After Early PCI for STEMI; DANAMI-3–PRIMULTI, Primary PCI in Patients With ST-Elevation Myocardial Infarction and Multivessel Disease: Treatment of Culprit Lesion Only or Complete Revascularization; HELP AMI, Hepacoat for Culprit or Multivessel Stenting for Acute Myocardial Infarction; MH random, random-effects model using the Mantel-Haenszel method; and PRAMI, Preventive Angioplasty in Myocardial Infarction.
Figure 4.
Figure 4.. Forest Plot of Long-term Cardiovascular Death Stratified by Approach in Patients With Complete Revascularization or Culprit-Lesion-Only Percutaneous Coronary Intervention (PCI)
Patients were stratified by a fractional flow reserve (FRR)– vs angiography-guided nonculprit-lesion approach. Size of markers represents weight. Squares and diamonds indicate odds ratios (ORs); error bars, 95% CIs. COMPLETE indicates Complete vs Culprit-Only Revascularization to Treat Multivessel Disease After Early PCI for STEMI; CvLPRIT, Complete vs Lesion-Only Primary PCI Trial; DANAMI-3–PRIMULTI, Primary PCI in Patients With ST-Elevation Myocardial Infarction and Multivessel Disease: Treatment of Culprit Lesion Only or Complete Revascularization; HELP AMI, Hepacoat for Culprit or Multivessel Stenting for Acute Myocardial Infarction; MH random, random-effects model using the Mantel-Haenszel method; and PRAMI, Preventive Angioplasty in Myocardial Infarction.
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