Key result
Direct stenting was associated with lower overall mortality compared to stenting with pre-dilation in patients with STEMI (OR 0.56; 95% CI 0.37-0.86; P=0.008).
Why the study?
Does direct stenting reduce mortality compared to stenting with pre-dilation in patients with STEMI?
Meta-Analysis (n=9,331)
Does direct stenting reduce mortality compared to stenting with pre-dilation in patients with STEMI?
Direct stenting in STEMI may improve clinical and procedural outcomes compared to pre-dilation, but definitive conclusions are limited by the reliance on non-randomized data and potential publication bias.
May support direct stenting in STEMI to lower mortality; leaves open confirmation by randomized trials.
OBJECTIVES: This study aimed at comparing direct stenting (DS) versus stenting with pre-dilation (SP) in patients with ST-elevation myocardial infarction (STEMI), using a systematic review and meta-analysis of published evidence. BACKGROUND: There is conflicting evidence whether stenting strategy impacts clinical outcomes in patients with STEMI. METHODS: We searched EMBASE, MEDLINE, and CENTRAL, from inception to December 2014. The primary endpoint was mortality. Secondary endpoints included major adverse cardiac events (MACEs), ST-segment resolution, and angiographic outcomes. RESULTS: A total of 9,331 patients enrolled in 12 studies (3 randomized controlled trials, RCTs; 9 non-randomized studies, NRSs) were included. DS was associated with lower mortality (OR 0.55; 95%CI: 0.33-0.94; P = 0.03) in NRSs, and overall (OR 0.56; 95%CI: 0.37-0.86; P = 0.008). Mortality was non-significantly reduced in RCTs (OR 0.56; 95%CI: 0.26-1.23; P = 0.15). DS was also associated with lower MACE rate (OR 0.71; 95%CI 0.60-0.84; P < 0.0001) in NRSs, but not in RCTs (OR 0.99; 95%CI: 0.61-1.60; P = 0.96). ST-segment resolution, no reflow, final thrombolysis in myocardial infarction (TIMI) flow and final TIMI myocardial perfusion or blush grade were significantly better with DS in NRSs, and non-significantly better in RCTs. CONCLUSIONS: The available evidence suggests that DS in STEMI might be associated with better clinical and procedural outcomes, as compared with SP. However, the fact that RCTs account for the minority of available data and that most of the available studies poorly reflect current clinical practice, as well as the existence of publication bias, preclude drawing definitive conclusions.
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Azzalini et al. (2015) conducted a meta-analysis in ST-elevation myocardial infarction (STEMI) (n=9,331). Direct stenting vs. Stenting with pre-dilation was evaluated on Mortality (OR 0.56, 95% CI 0.37-0.86, p=0.008). Direct stenting was associated with lower overall mortality compared to stenting with pre-dilation in patients with STEMI (OR 0.56; 95% CI 0.37-0.86; P=0.008).
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