Key result
Complete MV-PCI reduces MACE ~41% versus non-complete MV-PCI in STEMI with multivessel disease.
Why the study?
Current guidelines recommend culprit-only revascularisation in stable STEMI patients with multivessel disease, but recent RCTs suggest improved outcomes with complete multivessel PCI.
Does complete MV-PCI reduce MACE in patients with STEMI and multivessel disease compared to non-complete MV-PCI?
Meta-Analysis (n=1,303)
Does complete MV-PCI reduce MACE in patients with STEMI and multivessel disease compared to non-complete MV-PCI?
Odds Ratio: 0.59 (95% CI 0.36–0.97)
p-value: p=0.04
In patients with STEMI and multivessel disease, complete revascularization during the index procedure significantly reduces MACE compared to culprit-only or staged approaches, primarily driven by fewer recurrent MIs and repeat revascularizations.
Supports complete MV-PCI in STEMI multivessel disease to lower MACE; reinforces pooled RCT evidence for guideline adoption.
BACKGROUND: Current guidelines recommend culprit-only revascularisation (COR) in haemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI) and multivessel (MV) disease. Contrarily, growing body of evidence available from recent randomised controlled trials (RCTs) demonstrates improved outcomes with complete MV-percutaneous coronary intervention (PCI). METHODS AND RESULTS: We performed a meta-analysis of RCTs comparing complete MV-PCI with non-complete MV-PCI in STEMI and MV disease. Complete MV-PCI was defined as revascularisation to non-infarct-related artery lesions during index procedure, non-complete MV-PCI-encompassed COR and staged approaches. Multiple databases and congress proceedings from major cardiovascular societies' meetings were screened for relevant studies. Primary endpoint was the composite of major adverse cardiac events (MACE) typically defined as death, recurrent myocardial infarction (MI) and repeat revascularisation. Secondary endpoints were cardiovascular mortality, recurrent MI and repeat revascularisation. Outcomes were analysed at longest available follow-up with differences accounted for with adjusted models by person-years. Seven RCTs (N=1303) were included. The median follow-up was 12 months. Complete MV-PCI reduced the odds of MACE compared with non-complete MV-PCI (OR (95% CIs) 0.59 (0.36 to 0.97), p=0.04) driven by reduction in recurrent MI (0.48 (0.27 to 0.85), p=0.01) and repeat revascularisation (0.51 (0.31 to 0.84), p=0.008). Complete MV-PCI was associated with a non-significant trend towards reduced cardiovascular mortality (0.54 (0.26 to 1.10), p=0.09) as well. In a sensitivity analysis, none of the baseline clinical variables significantly influenced overall estimates. CONCLUSIONS: In STEMI and MV disease, complete MV-PCI as compared with non-complete strategy reduces MACE by 41%, driven by a 52% reduction in recurrent MI and 49% reduction in repeat revascularisation.
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Kowalewski et al. (2015) conducted a meta-analysis in ST-elevation myocardial infarction (STEMI) and multivessel (MV) disease (n=1,303). Complete MV-PCI vs. Non-complete MV-PCI (culprit-only revascularisation and staged approaches) was evaluated on Composite of major adverse cardiac events (MACE) defined as death, recurrent MI, and repeat revascularisation (OR 0.59, 95% CI 0.36 to 0.97, p=0.04). Complete MV-PCI reduced the odds of MACE compared with non-complete MV-PCI in patients with STEMI and multivessel disease (OR 0.59; 95% CI 0.36-0.97; p=0.04).
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