Complete vs Culprit-Only Percutaneous Coronary Intervention in STEMI With Multivessel Disease: A Meta-analysis and Trial Sequential Analysis of Randomized Trials

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• 作者：Kevin R. Bainey ; MD ; MSc^a ; ^{kevin.bainey@ualbertahealthservices.ca} ; Robert C. Welsh ; MD^a ; Bora Toklu ; MD^b ; Sripal Bangalore ; MD ; MHA^b
• 刊名：Canadian Journal of Cardiology
• 出版年：2016
• 出版时间：December 2016
• 年：2016
• 卷：32
• 期：12
• 页码：1542-1551
• 全文大小：2428 K
• 卷排序：32

文摘

Patients with ST-elevation myocardial infarction (STEMI) and multivessel disease (MVD) most commonly are treated with culprit-only percutaneous coronary intervention (PCI). However, this has been recently challenged, suggesting benefit with complete revascularization (CR). Still, these latest findings are largely based on clinical trials powered for composite outcomes that frequently include “softer” end points. We performed a meta-analysis comparing routine culprit-only PCI vs CR in STEMI, with an emphasis on “hard” clinical end points.MethodsMEDLINE, EMBASE, ISI Web of Science, and CENTRAL were searched from 1996-May 2015. Studies included patients with STEMI and MVD who received primary PCI. The primary end point was long-term death/myocardial infarction (MI). Data were combined using a fixed-effects model.ResultsSeven randomized trials (2004 patients: 1065 CR and 939 culprit-only PCI procedures) were included. Compared with culprit-only PCI, CR reduced the composite of death/MI (odds ratio [OR], 0.71; 95% confidence interval [CI], 0.52-0.96) but not death (OR, 0.78; 95% CI, 0.53-1.15) or recurrent MI (OR, 0.85; 95% CI, 0.58-1.24) alone. If CR was performed during the index catheterization, a reduction in death/MI was observed (death/MI: OR, 0.41; 95% CI, 0.25-0.65; death: OR, 0.59; 95% CI, 0.34-1.00; recurrent MI: OR, 0.35; 95% CI, 0.18-0.69). If staged, no benefits were noted (death/MI: OR, 0.99; 95% CI, 0.67-1.45; death: OR, 0.95; 95% CI, 0.56-1.61; recurrent MI: OR, 1.02; 95% CI, 0.61-1.70). However, when trial sequential analysis was performed for the overall population, the cumulative z-curve did not cross the monitoring boundary, suggesting a lack of evidence for reducing death/MI with CR (similar for index catheterization).ConclusionsIn STEMI with MVD, there is insufficient evidence to support a reduction in death/MI with CR. Our results reinforce the need for larger clinical trials powered for robust clinical end points.