Culprit-only versus multivessel percutaneous coronary intervention for multivessel disease in patients with st-elevation myocardial infarction: evidence from a 30,886-patient meta-analysis Giuseppe Biondi Zoccai Division of Cardiology, University of Turin, Turin, Italy
Background and Aim • There is uncertainty on the most appropriate management of patients with acute Stelevation myocardial infarction (STEMI) and concomitant multivessel coronary artery disease. • We thus performed a systematic review and meta-analysis comparing a culprit-only vs. multivessel percutaneous coronary intervention (PCI) in this setting.
Methods • Pertinent controlled clinical studies including 30 or more patients and comparing a culprit-only vs. multivessel PCI strategy in patients with STEMI were systematically searched in several databases. • The primary end-point was the rate of major adverse cardiac events (MACE, i.e. the composite of death, recurrent myocardial infarction, or repeat revascularization). • Secondary end-points included individual components of MACEs. Risk differences (RD, with 95% confidence intervals) were computed using random-effect methods.
Results • From a total of 687 citations, 10 clinical trials were shortlisted (with only 1 randomized study), including 30,886 patients with STEMI and concomitant multivessel disease, treated with a culprit-only vs. multivessel PCI, and followed for a median of 12 months after discharge. • Meta-analytic pooling showed similar 12-month rates of MACEs (RD=-3% [-9%; +3%], p=0.33), death (RD=-1% [-3%; +1%], p=0.23), recurrent myocardial infarction (RD=-2% [-8%; +3%], p=0.40,) or repeat revascularization (RD=0% [-6%; 5%], p=0.88).
Results • After an average follow-up of 24±15 months, unadjusted rates of MACE were 17.7% vs. 16.4%, with death in 2.7% vs 4.9%, myocardial infarction in 4.4% vs. 3.7%, TLR in 15.0% vs. 12.3%, and stent thrombosis in 3.1% vs. 2.7% (all p>0.05). • Even at extensive multivariable analysis with propensity adjustment, IVUS guidance was not associated with any statistically significant impact on the risk of MACE, death, myocardial infarction, TLR (neither on the main branch nor on the side branch), or stent thrombosis (all p>0.05).
Conclusions • Despite the fact that multivessel coronary disease detrimentally impacts on the prognosis of STEMI patients, a culprit-only revascularization strategy should be sought after in most cases, unless patient instability or symptoms/signs of residual myocardial ischemia clearly support non-culprit vessel intervention.
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