Author + information
- Received October 17, 2016
- Revision received November 22, 2016
- Accepted November 30, 2016
- Published online February 20, 2017.
- Islam Y. Elgendy, MDa,∗ (, )
- Ahmed N. Mahmoud, MDa,
- Dharam J. Kumbhani, MD, SMb,
- Deepak L. Bhatt, MD, MPHc and
- Anthony A. Bavry, MD, MPHa,d
- aDepartment of Medicine, University of Florida, Gainesville, Florida
- bDepartment of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- cBrigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
- dNorth Florida/South Georgia Veterans Health Systems, Gainesville, Florida
- ↵∗Address for correspondence:
Dr. Islam Y. Elgendy, Department of Medicine, Division of Cardiovascular Medicine, University of Florida, 1600 SW Archer Road, Gainesville, Florida 32610.
Objectives The authors sought to compare the effectiveness of the different revascularization strategies in ST-segment elevation myocardial infarction (STEMI) patients with multivessel coronary artery disease undergoing primary percutaneous coronary intervention (PCI).
Background Recent randomized trials have suggested that multivessel complete revascularization at the time of primary percutaneous coronary intervention (PCI) is associated with better outcomes, however; the optimum timing for nonculprit PCI is unknown.
Methods Trials that randomized STEMI patients with multivessel disease to any combination of the 4 different revascularization strategies (i.e., complete revascularization at the index procedure, staged procedure during the hospitalization, staged procedure after discharge or culprit-only revascularization) were included. Random effect risk ratios (RRs) were conducted. Network meta-analysis was constructed using mixed treatment comparison models, and the 4 revascularization strategies were compared.
Results A total of 10 trials with 2,285 patients were included. In the pairwise meta-analysis, complete revascularization (i.e., at the index procedure or as a staged procedure) was associated with a lower risk of major adverse cardiac events (MACE) (RR: 0.57; 95% confidence interval [CI]: 0.42 to 0.77), due to lower risk of urgent revascularization (RR: 0.44; 95% CI: 0.30 to 0.66). The risk of all-cause mortality (RR: 0.76; 95% CI: 0.52 to 1.12), and spontaneous reinfarction (RR: 0.54; 95% CI: 0.23 to 1.27) was similar. The reduction in the risk of MACE was observed irrespective of the timing of nonculprit artery revascularization in the mixed treatment model.
Conclusions Current evidence from randomized trials suggests that the risk of all-cause mortality and spontaneous reinfarction is not different among the various revascularization strategies for multivessel disease. Complete revascularization at the index procedure or as a staged procedure (either during the hospitalization or after discharge) was associated with a reduction of MACE due to reduction in urgent revascularization with no difference between these 3 strategies. Future trials are needed to determine the impact of complete revascularization on the risk of all-cause mortality and spontaneous reinfarction.
Dr. Kumbhani has received honoraria and research support from the American College of Cardiology. Dr. Bhatt has served on the advisory boards of Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, and Regado Biosciences; has served on the boards of directors of the Boston VA Research Institute and Society of Cardiovascular Patient Care; has chaired the American Heart Association Quality Oversight Committee; has served on data monitoring committees for the Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, and 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), Duke Clinical Research Institute (clinical trial steering committees), Harvard Clinical Research Institute (clinical trial steering committee), HMP Communications (editor in chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (guest editor; associate editor), Population Health Research Institute (clinical trial steering committee), Slack Publications (chief medical editor, Cardiology Today's Intervention), Society of Cardiovascular Patient Care (secretary/treasurer), and WebMD (CME steering committees); has had other relationships with Clinical Cardiology (deputy editor), NCDR-ACTION Registry Steering Committee (chair), and VA CART Research and Publications Committee (chair); has received research funding from Amarin, Amgen, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Forest Laboratories, Lilly, Ischemix, Medtronic, Pfizer, Roche, Sanofi, and The Medicines Company; has received royalties from Elsevier (editor, Cardiovascular Intervention: A Companion to Braunwald's Heart Disease); has served as a site coinvestigator for Biotronik, Boston Scientific, and St. Jude Medical; has been a trustee for the American College of Cardiology; and has performed unfunded research for FlowCo, PLx Pharma, and Takeda. Dr. Bavry has received 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. The first two authors contributed equally to this work.
- Received October 17, 2016.
- Revision received November 22, 2016.
- Accepted November 30, 2016.
- American College of Cardiology Foundation