Author + information
- Jacqueline E. Tamis-Holland, MD∗ (, )
- Eric Bates, MD and
- John Bittl, MD
- ↵∗Mount Sinai Saint Luke’s Hospital, Department of Cardiology, 1111 Amsterdam Avenue, New York, New York 10025
In a recent paper by Tarantini et al. (1), the authors performed a meta-analysis of studies evaluating the various strategies for the management of patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease. They demonstrated that staged multivessel percutaneous coronary intervention (PCI) was associated with a lower mortality as compared with infarct-related artery only PCI (IRA PCI) or multivessel PCI at the time of primary PCI (MV PPCI). In their analysis, the investigators categorized studies as “prospective” or “retrospective.” By grouping the studies in this manner, they included some of the observational studies into the prospective category. Prospective randomized controlled trials (RCT) are generally regarded as a stronger source of evidence than prospective observational studies and are not often grouped together in meta-analyses. One way to synthesize evidence from various sources is to use a Bayesian cross-design meta-analysis, but it does not seem that the statistical methods the authors used employed such an approach. As such, we believe that the results of the analysis provide misleading information regarding the outcomes related to the various PCI strategies in patients with STEMI and multivessel disease.
Regarding the outcomes for patients undergoing IRA PCI versus MV PPCI, we feel that the nonrandomized studies should be excluded from this prospective analysis. We previously showed that there is a trend toward lower mortality with MV PPCI when results from the RCTs alone are pooled (2). In contrast, no difference in outcomes between IRA PCI or MV PPCI could be found using a Bayesian cross-design meta-analysis, which included both observational studies as well as RCTs (3).
We also noticed that the authors included all of the patients enrolled in the CvLPRIT (Complete versus Lesion-only Primary PCI) trial in the MV PPCI group. In the CvLPRIT trial, 97 patients (70%) underwent MV PPCI and the remaining 42 (30%) underwent staged multivessel PCI. There was a trend toward a worse outcome in the group of patients having a staged procedure as compared with those undergoing MV PPCI (4). It is possible that the inclusion of patients undergoing staged MV PCI, into the MV PPCI group biased the results of this analysis against MV PCCI.
Finally, regarding the comparison of MV PPCI with staged multivessel PCI, we disagree with the inclusion of the nonrandomized studies in this prospective grouping. At present, there are very few RCTs (with a very small number of patients) comparing these 2 approaches; therefore, we do not feel a valid comparison can be made using the pooled data from RCTs.
Although we are in agreement with the conclusions that a strategy of stage MV PCI may offer some advantages over a strategy of IRA PCI, and theoretical advantages to MV PPCI, this opinion is based on clinical experience, but is not supported by the pooled results from the RCTs. The COMPLETE trial (Complete vs Culprit-Only Revascularization to Treat multi vessel Disease After Primary PCI for STEMI) (NCT01740479) will enroll 3900 patients to a strategy of staged MV PCI or an ischemia guided approach. We hope that this study will provide more definitive data regarding the potential advantages of staged MV PCI. Until there is more evidence to support one approach over another, physicians must use their clinical judgment to guide the treatment of patients with STEMI and multivessel disease.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- Tarantini G.,
- D’Amico G.,
- Brener S.J.,
- et al.
- Bates E.R.,
- Tamis-Holland J.R.,
- Bittl J.A.,
- O’Gara P.T.,
- Levine G.N.
- Gershlick A.H.,
- Khan J.N.,
- Kelly D.J.,
- et al.