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  • Cochrane corner: complete versus culprit-only revascularisation in ST segment elevation myocardial infarction with multivessel disease

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Editorial
Cochrane corner: complete versus culprit-only revascularisation in ST segment elevation myocardial infarction with multivessel disease
  1. Claudio A Bravo1,
  2. Sameer A Hirji2,
  3. Deepak L Bhatt3,
  4. Christian Gluud4,
  5. David P Faxon5,
  6. E Magnus Ohman6,
  7. Tsuyoshi Kaneko2,
  8. Thomas Engstrøm7,
  9. Dan Eik Høfsten7,
  10. J Matthew Brennan8
  1. 1Montefiore Einstein Center for Heart & Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
  2. 2Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
  3. 3Heart & Vascular Centre, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
  4. 4The Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
  5. 5Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
  6. 6Programme for Advanced Coronary Diseases, Division of Cardiovascular Medicine, Duke Heart Center, Ambulatory Care, Durham, North Carolina, USA
  7. 7Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
  8. 8Department of Medicine/Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
  1. Correspondence to Dr Claudio A Bravo, Montefiore Einstein Center for Heart & Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York 10461, USA; claudiobravo26{at}gmail.com

https://doi.org/10.1136/heartjnl-2017-312857

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    Background

    Approximately half of patients presenting to the hospital with an acutely occluded coronary artery that is causing ST segment elevation myocardial infarction (STEMI) have significant stenosis of other coronary arteries.1 Observational studies have shown that patients with STEMI along with multivessel disease (MVD) fare worse than those with single vessel disease.

    Timely revascularisation of the culprit coronary artery is considered crucial for the treatment of STEMI. However, the management of other diseased, non-culprit coronary vascular territories has been an area of considerable debate. Recently published randomised clinical trials (RCTs) suggesting a beneficial effect from complete revascularisation have led to changes in guidelines, now supporting intervention of non-culprit vessels (class IIa or IIb recommendation).2 3

    The goal of this Cochrane systematic review was to compare efficacy and safety of the culprit-only versus complete revascularisation strategies in patients with STEMI and MVD. Importantly, we also analysed comprehensively the quality of the evidence using the Cochrane standards.

    Methods

    We searched for RCTs comparing complete revascularisation versus culprit-only percutaneous coronary intervention (PCI) in adult patients (≥18 years old) with STEMI and MVD in the Cochrane Central Register, MEDLINE, EMBASE, WHO ICTRP Portal and ClinicalTrials.gov since their inception up to January 2017.4

    We extracted data on all-cause mortality, cardiovascular mortality, myocardial infarction, revascularisation and adverse events that included stroke, acute kidney injury and bleeding. The data were extracted on short-term (within the first 30 days after the index procedure) and long-term (1 year or greater after the index procedure) outcomes.

    Data were analysed as risk ratio (RR) with 95% CI, and we conducted analyses according to the statistical guidelines contained in the Cochrane Handbook for Systematic Reviews of Interventions.5 Furthermore, for trial sequential analysis (TSA),6 the required information size was calculated based on a 20% relative risk reduction (RRR) in the intervention group, a type …

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    Footnotes

    • CAB and SAH contributed equally.

    • Contributors CAB and SAH contributed equally to protocol writing, trial selection, data extraction, data analysis, data interpretation, review writing and future review updates. DLB, DPF, EMO, TK, TE, DEH and JMB contributed to data analysis, data interpretation and review writing. CG contributed to data analysis, data interpretation, review writing, as well as with TSA and GRADE expertise. CAB had full access to all of the data and takes responsibility for the integrity of the data and the accuracy of the data analysis. CAB and SAH are guarantors.

    • Competing interests None declared.

    • Provenance and peer review Commissioned; externally peer reviewed.

    • Data sharing statement No additional data are available.