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Percutaneous Coronary Revascularization Strategies After MI
Quick Takes
- All-cause mortality was reduced by 15% with complete revascularization compared with culprit revascularization.
- Furthermore, cardiovascular mortality, MI, MACE, and repeat revascularization were also reduced with complete revascularization compared with culprit-only revascularization.
- Given inherent limitations of a network meta-analysis, additional RCTs are needed to assess benefits of immediate complete revascularization as compared to staged complete revascularization, and for physiology-guided complete revascularization as compared to angiography-guided complete revascularization.
Study Questions:
What is the outcome of contemporary revascularization strategies in patients presenting with myocardial infarction (MI) and multivessel coronary artery disease (CAD)?
Methods:
The investigators performed an updated systematic review with frequentist and Bayesian network meta-analyses including the totality of randomized data investigating revascularization strategies in patients presenting with MI and multivessel CAD. They primarily tested complete versus culprit revascularization. Timing and methods of achieving complete revascularization were assessed. The prespecified primary outcome was all-cause mortality, chosen as the most bias-resistant and clinically meaningful outcome. Secondary efficacy outcomes were cardiovascular mortality, MI, major adverse cardiac events (MACE), and repeat revascularization. The conventional pairwise meta-analyses were performed with random effects models fitted using the restricted maximum likelihood estimator. Outcomes were expressed as relative risk (RR) (95% confidence interval [CI]).
Results:
Twenty-four eligible trials randomized 16,371 patients (weighted mean follow-up: 26.4 months). Compared with culprit revascularization, complete revascularization reduced all-cause mortality in patients with any MI (RR, 0.85; 95% CI, 0.74-0.99; p = 0.04). Cardiovascular mortality, MI, MACE, and repeat revascularization were also significantly reduced. In patients presenting with ST-segment elevation MI, the point estimate for all-cause mortality with complete revascularization was RR, 0.91 (95% CI, 0.78-1.05; p = 0.18). Rates of stent thrombosis, major bleeding, and acute kidney injury were similar. Immediate complete revascularization ranked higher than staged complete revascularization for all endpoints.
Conclusions:
The authors report that complete revascularization following MI reduces all-cause mortality, cardiovascular mortality, MI, MACE, and repeat revascularization.
Perspective:
This network meta-analysis of 24 trials reports that all-cause mortality was reduced by 15% with complete revascularization compared with culprit revascularization. Furthermore, cardiovascular mortality, MI, MACE, and repeat revascularization were also reduced with complete revascularization compared with culprit-only revascularization. Of note, there were no significant differences in all-cause or cardiovascular mortality between immediate and staged complete revascularization in this analysis, but immediate complete revascularization led to reduced rates of MI and MACE compared with staged complete revascularization.
Given inherent limitations of a network meta-analysis, additional randomized controlled trials (RCTs) are needed to assess benefits of immediate complete revascularization as compared to staged complete revascularization, and for physiology-guided complete revascularization as compared to angiography-guided complete revascularization. Finally, for the majority of nonculprit lesions that are not critically stenosed in patients with MI, treatment using angiography alone to guide decision-making may not be insufficient.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention
Keywords: Myocardial Infarction, Myocardial Revascularization
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