Angiography-guided complete revascularization reduced the risk of all-cause mortality or myocardial infarction by 32% (RR 0.68) compared to culprit-only revascularization in STEMI patients with multivessel disease.
Meta-Analysis (n=8,233)
Does complete revascularization (angiography-guided or FFR-guided) reduce the composite of all-cause mortality or MI in STEMI patients with multivessel disease compared to culprit-only revascularization?
In STEMI patients with multivessel disease, angiography-guided complete revascularization was associated with a lower risk of mortality or MI compared to both culprit-only revascularization and FFR-guided complete revascularization.
Effect estimate: RR 0.68 (95% CI 0.50-0.87)
Whether fractional flow reserve (FFR) should be available for revascularization in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) is controversial. We aimed to compare the efficacy of various complete revascularization (CR) regimens for STEMI patients with MVD. The PubMed and Cochrane Library databases and clinicaltrial.gov were searched for the randomized controlled trials (RCTs) comparing the FFR-guided CR, angiography-guided CR, and culprit-only revascularization (COR) strategies in STEMI patients with MVD. A Bayesian random-effect model was employed to synthesize the evidence in network meta-analysis. We used relative risk (RR) and 95% credible interval (CrI) as measures of effect size. The primary endpoint was the composite outcome of all-cause mortality or myocardial infarction (MI). Twelve RCTs were included. Angiography-guided CR showed a lower event rate of the composite outcome (RR, 0.68; 95%CrI, 0.50-0.87), all-cause mortality (RR, 0.75; 95%CrI, 0.55-0.96), MI (RR, 0.63; 95%CrI, 0.43-0.86), and repeat revascularization (RR, 0.36; 95% CrI, 0.24-0.55) compared with COR. Additionally, angiography-guided CR had a lower risk of primary outcome (RR, 0.64; 95%CrI, 0.38-0.94) and MI (RR, 0.58; 95%CrI, 0.31-0.92) than FFR-guided CR. The difference between the FFR-guided CR and COR in terms of composite outcome, all-cause mortality, and MI was similar. Angiography-guided CR was associated with the highest probability of optimal treatment for the primary outcome (98.5%), followed by FFR-guided CR (1.2%) and COR (0.3%). STEMI patients with MVD benefitted more from angiography-guided CR than from FFR-guided CR. However, only one study compared the effectiveness of FFR-guided and angiography-guided PCI; thus, the comparison between FFR-guided and angiography-guided PCI relied on indirect evidence. Therefore, further studies directly comparing the effectiveness of these two CR strategies are warranted.
Zhao et al. (Thu,) conducted a meta-analysis in ST-segment elevation myocardial infarction and multivessel disease (n=8,233). Angiography-guided complete revascularization vs. Culprit-only revascularization was evaluated on Composite outcome of all-cause mortality or myocardial infarction (RR 0.68, 95% CI 0.50-0.87). Angiography-guided complete revascularization reduced the risk of all-cause mortality or myocardial infarction by 32% (RR 0.68) compared to culprit-only revascularization in STEMI patients with multivessel disease.