Elsevier

International Journal of Cardiology

Volume 179, 20 January 2015, Pages 552-557
International Journal of Cardiology

Management of multivessel coronary disease in STEMI patients: A systematic review and meta-analysis

https://doi.org/10.1016/j.ijcard.2014.10.035Get rights and content

Highlights

  • Management of multivessel coronary artery disease for STEMI patients remains to be determined

  • Current evidence is fraught by mixed analysis of randomized and observational not adjusted studies

  • Multivessel revascularization in patients with STEMI reduces long term revascularization, without increasing in hospital risk

  • Both the approaches reduce revascularization at long term follow up.

Abstract

Background

Appropriate management for patients with multivessel coronary disease presenting with ST segment Elevation Myocardial Infarction (STEMI) remains to be defined.

Methods and results

Medline and Cochrane Library were searched for randomized controlled trials (RCTs) or observational studies adjusted with multivariate analysis, reporting about STEMI patients with multivessel coronary disease treated with either a culprit only or complete revascularization strategy, excluding patients in cardiogenic shock. Prespecified analysis was performed according to the strategy of complete revascularization, either during the same procedure of primary percutaneous coronary intervention (PCI) or during the index hospitalization. MACE (a composite and mutually exclusive end point of death or myocardial infarction or revascularization) at follow-up of at least one year was the primary end point.

9 studies with 4686 patients compared culprit only versus complete PCI performed during the primary PCI. Rates of MACE did not differ at 90 days (OR 0.70 [0.38, 1.27], I2 = 0%) or at 1 year (1–2.5) (OR 0.70 [0.47, 1.03], I2 = 0%). No significant difference was found for the components of the primary outcome, apart from a reduction in repeated revascularization for patients undergoing complete PCI during the STEMI procedure (OR 0.62 [0.39, 0.98], I2 = 0%).

6 studies (1 RCT) with 5855 patients compared culprit only lesions versus complete PCI performed during index hospitalization. 90 day risk of MACE did not differ nor 1 year (1–2.5) MACE (OR 0.86 [0.62, 1.08], I2 = 0%), with a similar reduction in repeated revascularization (0.60 [0.40, 0.90], I2 = 0%).

Conclusions

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.

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.

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