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Meta-Analysis
. 2020 Jun 16;9(12):e015263.
doi: 10.1161/JAHA.119.015263. Epub 2020 Jun 1.

Complete Revascularization by Percutaneous Coronary Intervention for Patients With ST-Segment-Elevation Myocardial Infarction and Multivessel Coronary Artery Disease: An Updated Meta-Analysis of Randomized Trials

Yousif Ahmad  1   2 , James P Howard  2 , Ahran Arnold  2 , Megha Prasad  1 , Henry Seligman  2 , Christopher M Cook  2 , Takayuki Warisawa  2 , Matthew Shun-Shun  2 , Ziad Ali  1 , Manish A Parikh  1 , Rasha Al-Lamee  2 , Sayan Sen  2 , Darrel Francis  2 , Jeffrey W Moses  1 , Martin B Leon  1 , Gregg W Stone  3   4 , Dimitri Karmpaliotis  1
Affiliations
Meta-Analysis

Complete Revascularization by Percutaneous Coronary Intervention for Patients With ST-Segment-Elevation Myocardial Infarction and Multivessel Coronary Artery Disease: An Updated Meta-Analysis of Randomized Trials

Yousif Ahmad et al. J Am Heart Assoc. .

Abstract

Background For patients with ST-segment-elevation myocardial infarction (STEMI) and multivessel coronary artery disease, the optimal treatment of the non-infarct-related artery has been controversial. This up-to-date meta-analysis focusing on individual clinical end points was performed to further evaluate the benefit of complete revascularization with percutaneous coronary intervention for patients with STEMI and multivessel coronary artery disease. Methods and Results We systematically identified all randomized trials comparing complete revascularization with percutaneous coronary intervention to culprit-only revascularization for multivessel disease in STEMI and performed a random-effects meta-analysis. The primary efficacy end point was cardiovascular death analyzed on an intention-to-treat basis. Secondary end points included all-cause mortality, myocardial infarction, and unplanned revascularization. Ten studies (7542 patients) were included: 3664 patients were randomized to complete revascularization and 3878 to culprit-only revascularization. Across all patients, complete revascularization was superior to culprit-only revascularization for reduction in the risk of cardiovascular death (relative risk [RR], 0.68; 95% CI, 0.47-0.98; P=0.037; I2=21.8%) and reduction in the risk of myocardial infarction (RR, 0.65; 95% CI, 0.54-0.79; P<0.0001; I2=0.0%). Complete revascularization also significantly reduced the risk of unplanned revascularization (RR, 0.37; 95% CI, 0.28-0.51; P<0.0001; I2=64.7%). The difference in all-cause mortality with percutaneous coronary intervention was not statistically significant (RR, 0.85; 95% CI, 0.69-1.04; P=0.108; I2=0.0%). Conclusions For patients with STEMI and multivessel disease, complete revascularization with percutaneous coronary intervention significantly improves hard clinical outcomes including cardiovascular death and myocardial infarction. These data have implications for clinical practice guidelines regarding recommendations for complete revascularization following STEMI.

Keywords: ST‐segment–elevation myocardial infarction; percutaneous coronary intervention; revascularization.

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Figures

Figure 1
Figure 1. Search strategy and source of included studies. CTO indicates chronic total occlusion.
Figure 2
Figure 2. Effect of complete revascularization on cardiovascular death.
Compare Acute indicates Fractional Flow Reserve–Guided Multivessel Angioplasty in Myocardial Infarction; COMPLETE, Complete versus Culprit‐Only Revascularization Strategies to Treat Multivessel Disease after Early PCI for STEMI; CvLPRIT, Complete Versus Lesion‐Only Primary PCI trial; DANAMI 3 PRIMULTI, Complete revascularisation versus treatment of the culprit lesion only in patients with ST‐segment–elevation myocardial infarction and multivessel disease; PRAMI, Preventive Angioplasty in Acute Myocardial Infarction.
Figure 3
Figure 3. Effect of complete revascularization on myocardial infarction.
Compare Acute, Fractional Flow Reserve–Guided Multivessel Angioplasty in Myocardial Infarction; COMPLETE, Complete versus Culprit‐Only Revascularization Strategies to Treat Multivessel Disease after Early PCI for STEMI; CvLPRIT, Complete Versus Lesion‐Only Primary PCI trial; DANAMI 3 PRIMULTI, Complete revascularisation versus treatment of the culprit lesion only in patients with ST‐segment–elevation myocardial infarction and multivessel disease; HELP‐AMI, Hepacoat for Culprit or Multivessel Stenting for Acute Myocardial Infarction; PRAMI, Preventive Angioplasty in Acute Myocardial Infarction.
Figure 4
Figure 4. Effect of complete revascularization on all‐cause mortality.
Compare Acute, Fractional Flow Reserve–Guided Multivessel Angioplasty in Myocardial Infarction; COMPLETE, Complete versus Culprit‐Only Revascularization Strategies to Treat Multivessel Disease after Early PCI for STEMI; CvLPRIT, Complete Versus Lesion‐Only Primary PCI trial; DANAMI 3 PRIMULTI, Complete revascularisation versus treatment of the culprit lesion only in patients with ST‐segment–elevation myocardial infarction and multivessel disease; HELP‐AMI, Hepacoat for Culprit or Multivessel Stenting for Acute Myocardial Infarction; PRAMI, Preventive Angioplasty in Acute Myocardial Infarction.
Figure 5
Figure 5. Effect of complete revascularization on unplanned revascularization.
Compare Acute, Fractional Flow Reserve–Guided Multivessel Angioplasty in Myocardial Infarction; COMPLETE, Complete versus Culprit‐Only Revascularization Strategies to Treat Multivessel Disease after Early PCI for STEMI; CvLPRIT, Complete Versus Lesion‐Only Primary PCI trial; DANAMI 3 PRIMULTI, Complete revascularisation versus treatment of the culprit lesion only in patients with ST‐segment–elevation myocardial infarction and multivessel disease; HELP‐AMI, Hepacoat for Culprit or Multivessel Stenting for Acute Myocardial Infarction; PRAMI, Preventive Angioplasty in Acute Myocardial Infarction.
Figure 6
Figure 6. Effect of complete revascularization on major bleeding.
Compare Acute, Fractional Flow Reserve–Guided Multivessel Angioplasty in Myocardial Infarction; COMPLETE, Complete versus Culprit‐Only Revascularization Strategies to Treat Multivessel Disease after Early PCI for STEMI; CvLPRIT, Complete Versus Lesion‐Only Primary PCI trial; DANAMI 3 PRIMULTI, Complete revascularisation versus treatment of the culprit lesion only in patients with ST‐segment–elevation myocardial infarction and multivessel disease; PRAMI, Preventive Angioplasty in Acute Myocardial Infarction.
Figure 7
Figure 7. Effect of timing of complete revascularization on cardiovascular (CV) death.
Compare Acute, Fractional Flow Reserve–Guided Multivessel Angioplasty in Myocardial Infarction; COMPLETE, Complete versus Culprit‐Only Revascularization Strategies to Treat Multivessel Disease after Early PCI for STEMI; CvLPRIT, Complete Versus Lesion‐Only Primary PCI trial; DANAMI 3 PRIMULTI, Complete revascularisation versus treatment of the culprit lesion only in patients with ST‐segment–elevation myocardial infarction and multivessel disease; PRAMI, Preventive Angioplasty in Acute Myocardial Infarction.
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