Meta-Analysis of Culprit-Only Versus Multivessel Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Disease

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Recently, several randomized controlled trials (RCT) in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) have compared a strategy of routine multivessel percutaneous coronary intervention (PCI) performed either as a single procedure or as staged procedures to culprit-only PCI. All of these trials have been underpowered for clinical end points. We searched PubMed, Embase, and Cochrane Central Register of Controlled Trials for RCT comparing multivessel PCI with culprit-only PCI in patients with STEMI and MVD. The primary efficacy outcome was the composite rate of death or MI. Other efficacy outcomes included death, MI, and repeat revascularization. Safety outcomes were contrast-associated acute kidney injury, stroke, and major bleeding. Pairwise direct comparison and mixed-treatment comparison network meta-analyses were performed. Eleven trials that enrolled 3,150 patients with a total of 5,296 patient-years of follow-up were included. In direct comparison meta-analysis, single-procedure multivessel PCI was associated with a reduction in the risk of death or MI (rate ratio [RR] = 0.52; 95% confidence interval [CI] 0.37 to 0.73; p <0.001), due to less death (RR = 0.64; 95% CI 0.40 to 1.02; p = 0.06) and MI (RR = 0.42; 95% CI 0.25 to 0.69; p <0.0001) compared with culprit-only PCI. No heterogeneity (I2 = 0) was present between studies. In contrast, staged multivessel PCI did not significantly reduce death or MI compared with culprit-only PCI. Both multivessel PCI strategies reduced the risk of repeat revascularization without significant differences in safety outcomes. Results were consistent in the mixed-treatment comparison meta-analysis. In conclusion, the present meta-analysis suggests that single-procedure multivessel PCI may be the preferred strategy in patients with STEMI and MVD.

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Methods

We searched PubMed, Embase, and Cochrane Central Register of Controlled Trials through May 31, 2017, for RCTs that enrolled patients with STEMI and MVD, and compared the following PCI strategies: (1) single-procedure multivessel PCI; (2) staged multivessel PCI; and (3) culprit-only PCI. The Medical Subject Headings terms are listed in Supplementary Table 1. There was no language restriction for the search. We kept the search current by setting up automated reminders from PubMed for new

Results

We identified 11 RCTs that enrolled 3,150 patients with STEMI and MVD (Supplementary Figure 1), who were followed for 1.6 ± 1.0 years (range 0.5 to 3.2 years), with a total of 5,296 patient-years of follow-up. The network of PCI strategy comparisons is shown in Figure 1. The baseline characteristics and bias risk assessments are outlined in Supplementary Tables 2 and 3. Two of the 11 trials included both a single-procedure and staged multivessel PCI strategy as part of the complete

Discussion

In the present meta-analysis of randomized trials of 3 different revascularization strategies in patients presenting with STEMI and MVD, single-procedure multivessel PCI was associated with a significant reduction in the composite rate of death or MI and repeat revascularization when compared with culprit-only PCI, with high consistency (no heterogeneity) between trials. Staged multivessel PCI was associated with a significant reduction in repeat revascularization, but not with death or MI when

Disclosures

The authors have no conflicts of interest to disclose.

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