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Original article
Complete revascularisation in ST-elevation myocardial infarction and multivessel disease: meta-analysis of randomised controlled trials
  1. Mariusz Kowalewski1,2,
  2. Volker Schulze2,3,
  3. Sergio Berti2,4,
  4. Ron Waksman5,
  5. Jacek Kubica2,6,
  6. Michalina Kołodziejczak2,6,
  7. Antonino Buffon7,
  8. Harry Suryapranata8,
  9. Paul Alfred Gurbel9,
  10. Malte Kelm2,3,
  11. Wojciech Pawliszak1,
  12. Lech Anisimowicz1,
  13. Eliano Pio Navarese2,3
  1. 1Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital in Bydgoszcz, Bydgoszcz, Poland
  2. 2Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Düsseldorf, Germany
  3. 3Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
  4. 4Department of Invasive Cardiology, Institute of Clinical Physiology, National Research Council, Pisa, Italy
  5. 5MedStar Washington Hospital Center, Washington, DC, USA
  6. 6Department of Cardiology and Internal Medicine, Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, Bydgoszcz, Poland
  7. 7Department of Cardiovascular Sciences, Catholic University of the Sacred Heart, Rome, Italy
  8. 8Department of Cardiology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
  9. 9Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
  1. Correspondence to Prof. Eliano Pio Navarese, MD, PhD, FESC, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany; eliano.navarese@alice.it or elianonavarese@gmail.com

Abstract

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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