Background:
Primary Percutaneous Coronary Intervention (PCI) is the preferred treatment for patients presenting with ST-elevation myocardial infarction (STEMI). Despite multiple randomized clinical trials (RCT) best revascularization strategy (RS) in patients with STEMI and multivessel disease (MVD) remains unknown. We aimed to use network meta-analysis to compare currently used approaches.
Methods:
We searched for RCT comparing RSs in patients with MVD undergoing PCI for STEMI. We identified and compared RCT with arms evaluating at least two of the following approaches: culprit only revascularization (CoR), complete revascularization during initial intervention (CR) and staged procedure with culprit vessel revascularization followed by non culprit significant lesions intervention during the initial hospitalization. Our primary outcome was all-cause mortality. We combined direct and indirect data to perform a network meta-analysis.
Results:
A total of 7,779 patients from 13 RCT were included in this analysis (Fig. 1). Overall, this is an unbalanced network with only 1 arm comparing CR and SR. Complete revascularization during initial procedure was associated with a significant reduction in mortality with RR 0.47 (0.34; 0.65), p<0.01, when compared to culprit only approach. There was a higher risk of mortality associated with SR, when compared to CR, with RR 1.9 (1.29; 2.82), p<0.01. There was no mortality risk difference between CoR and SR, RR 0.89 (0.72,1.11), p>0.5 (Fig. 2). There was no evidence of a model inconsistency in an overall comparison, p>0.21. There was a design by treatment interaction in SR vs CoR comparison, p<0.01.
Conclusion:
Complete revascularization during primary PCI in patients presenting with STEMI and MVD was associated with significant mortality reduction when compared to culprit only lesion revascularization. There may be design by treatment interaction limiting comparison of staged and culprit only strategies.
Postconditioning in ST-elevation myocardial infarction: a systematic review, critical appraisal, and meta-analysis of randomized clinical trials
