Management of multivessel coronary disease in STEMI patients: A systematic review and meta-analysis
Introduction
Forty percent of patients with STEMI (ST segment Elevation Myocardial Infarction) present with multivessel coronary disease (CAD) [1], [2] with a detrimental impact on prognosis and on freedom from recurrent cardiac events [3].
The optimal management of these patients, apart from those with cardiogenic shock, remains to be determined.
From a physiopathological point of view, plaques determining coronary stenosis not related to the culprit lesion may be evaluated either as a chronic condition [3], or as an expression of multiple unstable coronary lesions [4], [5], [6], [7], [8] with an unpredictable evolution.
Clinically these different concepts have been translated into at least three strategies. The most exploited one remains the “culprit only”, that is to treat only the lesion related to STEMI presentation, with subsequent decisions taken according to the presence of documented ischemia [9]. Alternatively, non-culprit lesions may be treated during the primary PCI (percutaneous coronary intervention) procedure [9] although with contrasting results around safety [11], [12] and adverse events during index hospitalization [13]. The meta-analysis of Vlaar et al. [18] demonstrated a substantial midterm survival benefit for those undergoing staged complete revascularization and a reduction in survival for those treated with complete revascularization during primary PCI. This paper, however, was based on pooled analysis of randomized controlled trials (RCTs) and observational data not adjusted through multivariate analysis: this lack of appraisal of severity and extent of coronary disease may have led to a high risk of selection bias involved in operators' decision to proceed with culprit versus multi-vessel PCI and may have influenced survival in this setting, as demonstrated by the recent PRAMI trial [12].
We therefore performed this meta-analysis to determine the best practice for STEMI patients with multivessel disease.
Section snippets
Methods
The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) amendment to the Quality of Reporting of Meta-analyses (QUOROM) statement, and recommendations from the Cochrane Collaboration and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) were followed during the development of the present systematic review [16], [17], [18].
Results
568 studies were appraised at the abstract level (Fig. 1): nine [19], [20], [21], [22], [23], [24], [25], [26], [27], [28] were excluded for lack of multivariate adjustment, one [29] because it enrolled only patients in cardiogenic shock and one [29] because it did not compare culprit versus complete PCI [30]. Finally thirteen [14], [15], [16], [17], [30], [31], [32], [33], [34], [35], [36], [37], [38] were included in the systematic review, with two of them comparing revascularization both
Discussion
The present meta-analysis demonstrated that: a) complete PCI when compared to culprit only PCI for STEMI patients with multivessel disease reduces need for subsequent revascularization; b) short term event rates are also not increased after a complete revascularization during primary PCI; and c) both of the two strategies about multivessel PCI (during primary PCI and during index hospitalization) perform similarly regarding to long term outcomes.
Management of residual coronary disease after a
Conclusion
Complete revascularization performed during primary PCI or index hospitalizations for patients presenting with STEMI appears safe at short term follow-up and offers a reduction in repeated revascularization at one year.
Contributorship statement
CM and FDA conceived the paper.
FDA performed the analysis.
The other authors wrote the paper.
References (53)
- et al.
Comparison of mortality rates in women versus men presenting with ST-segment elevation myocardial infarction
Am. J. Cardiol.
(Mar 1 2011) - et al.
Angioscopic follow-up study of coronary ruptured plaques in nonculprit lesions
J. Am. Coll. Cardiol.
(2005) - et al.
Plaque rupture and intracoronary thrombus in nonculprit vessels: an eyewitness account
J. Am. Coll. Cardiol.
(2005) - et al.
Atherosclerotic coronary plaque regression and the risk of adverse cardiovascular events: a meta-regression of randomized clinical trials
Atherosclerosis
(Jan 2013) - et al.
C-reactive protein and multiple complex coronary artery plaques in patients with primary unstable angina
Atherosclerosis
(2002) - et al.
Culprit vessel only versus multivessel and staged percutaneous coronary intervention for multivessel disease inpatients presenting with ST-segment elevation myocardial infarction: a pairwise and network meta-analysis
J. Am. Coll. Cardiol.
(2011) - et al.
Potential pitfalls of meta-analyses of observational studies in cardiovascular research
J. Am. Coll. Cardiol.
(2012) - et al.
Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses
Lancet
(1999) - et al.
Multivessel percutaneous coronary intervention in patients with multivessel disease and acute myocardial infarction
Am. Heart J.
(2004) - et al.
Culprit only versus complete coronary revascularization during primary PCI
Int. J. Cardiol.
(2008)