Author + information
- Islam Y. Elgendy, MD∗ (, )
- Ahmed N. Mahmoud, MD,
- Dharam J. Kumbhani, MD, SM,
- Deepak L. Bhatt, MD, MPH and
- Anthony A. Bavry, MD, MPH
- ↵∗University of Florida, Department of Medicine, Division of Cardiovascular Medicine, 1600 SW Archer Road, Gainesville, FL 32610
We appreciate the interest of Dr. Guo and colleagues in our recent meta-analysis (1). We agree that the timing of nonculprit artery revascularization might be an important factor, and therefore we performed a network meta-analysis comparing the outcomes according to the different timings of revascularization of the nonculprit artery (i.e., at the index procedure, staged during hospitalization, or after discharge) and demonstrated no differences among the revascularization strategies on hard outcomes of all-cause mortality and spontaneous reinfarction. Dr. Guo and colleagues performed a secondary analysis to compare complete revascularization of the nonculprit artery during hospitalization (i.e., at the time of the index procedure or before discharge) with culprit-only revascularization, and they noted that complete revascularization during hospitalization was associated with a reduction in the risk for major adverse cardiac events, with no statistical heterogeneity. It is important to note that performing subgroup analyses (aiming to explore the sources of heterogeneity) without testing for interaction might be misleading (2). Therefore, we performed an analysis comparing these strategies. Although the risk ratios for major adverse cardiac events were 0.49 (95% confidence interval: 0.39 to 0.60) for complete revascularization during hospitalization and 0.77 (95% confidence interval: 0.40 to 1.49) for complete revascularization after hospitalization, there was no evidence of an interaction (p = 0.11) (Figure 1), indicating that the timing of complete revascularization (i.e., during the hospitalization or after discharge) is not an obvious effect modifier. The small number of patients in the trials evaluating complete revascularization after discharge might explain the latter results. Another important consideration is that we analyzed only the risk for spontaneous myocardial infarction (MI), unlike the analysis of Dr. Guo and colleagues which analyzed any MI, since we believe that spontaneous MI is preferential to any MI and also because the definitions of periprocedural MI among the trials were inconsistent (1).
In summary, we believe that our findings add to the growing number of studies that support a complete revascularization approach (irrespective of the timing of revascularization of the nonculprit artery) because of reduction in the risk for major adverse cardiac events and revascularization. The optimal timing of revascularization of the nonculprit artery (i.e., during the index procedure vs. during hospitalization vs. after discharge) deserves evaluation in future studies. The COMPLETE trial is expected to provide important insights into this; results are expected in the next 1 to 2 years.
Please note: Dr. Kumbhani has received an honorarium and research support from the American College of Cardiology. Dr. Bhatt is a member of the advisory boards of Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, and Regado Biosciences; a member of the boards of directors of the Boston VA Research Institute and the Society of Cardiovascular Patient Care; is chair of the American Heart Association Quality Oversight Committee; is a member of the data monitoring committees of the Duke Clinical Research Institute, the Harvard Clinical Research Institute, the Mayo Clinic, and the Population Health Research Institute (including for the COMPLETE trial); has received honoraria from the American College of Cardiology (senior associate editor, Clinical Trials and News, ACC.org), Belvoir Publications (editor-in-chief, Harvard Heart Letter), the Duke Clinical Research Institute (clinical trial steering committees), the Harvard Clinical Research Institute (clinical trial steering committee), HMP Communications (editor-in-chief, Journal of Invasive Cardiology), the Journal of the American College of Cardiology (guest editor, associate editor), the Population Health Research Institute (clinical trial steering committee), Slack Publications (chief medical editor, Cardiology Today’s Intervention), and the Society of Cardiovascular Patient Care (secretary/treasurer), WebMD (continuing medical education steering committees); is deputy editor of Clinical Cardiology, chair of the NCDR-ACTION Registry Steering Committee, and chair of the VA CART Research and Publications Committee; has received research funding from Amarin, Amgen, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Forest Laboratories, Ischemix, Eli Lilly, Medtronic, Pfizer, Roche, Sanofi, and The Medicines Company; has received royalties from Elsevier (editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); is a site co-investigator for Biotronik, Boston Scientific, and St. Jude Medical; is a trustee of the American College of Cardiology; and has conducted unfunded research for FlowCo, PLx Pharma, and Takeda. Dr. Bavry has received an honorarium from the American College of Cardiology. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2017 American College of Cardiology Foundation
- Elgendy I.Y.,
- Mahmoud A.N.,
- Kumbhani D.J.,
- Bhatt D.L.,
- Bavry A.A.
- ↵O’Connor D, Green S, Higgins JP. 9.6.2. What are subgroup analyses? In: Higgins JP, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions. The Cochrane Collaboration; 2011. Available at: http://handbook.cochrane.org/chapter_9/9_6_2_what_are_subgroup_analyses.htm. Accessed March 30, 2017.