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Percutaneous Coronary Revascularization Strategies After Myocardial Infarction
TAKE-HOME MESSAGE
- This systematic review and network meta-analysis of 24 randomized trials evaluated the timing and outcomes of revascularization strategies in 16,371 patients with myocardial infarction (MI) and multivessel coronary artery disease. Complete revascularization was associated with significantly reduced risks of all-cause mortality, cardiovascular mortality, MI, major adverse cardiac events, and repeat revascularization compared with culprit-only revascularization. In addition, immediate complete revascularization outperformed staged revascularization across all endpoints.
- These findings suggest a potential role for complete revascularization in patients with MI and multivessel coronary artery disease, when feasible. Cardiologists should continue to leverage individualized clinical decision–making driven by patient clinical factors, procedural complexity, and operator experience. Further research is needed to clinically phenotype patients most likely to benefit from complete revascularization and establish the optimal timing of this intervention.
abstract
This abstract is available on the publisher's site.
Access this abstract now Full Text Available for ClinicalKey SubscribersBACKGROUND
Complete revascularization with percutaneous coronary intervention improves outcomes compared with culprit revascularization following myocardial infarction (MI) with multivessel coronary artery disease. An all-cause mortality reduction has never been demonstrated. Debate also remains regarding the optimal timing of complete revascularization (immediate or staged), and method of evaluation of nonculprit lesions (physiology or angiography).
OBJECTIVES
This study aims to perform 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 coronary artery disease.
METHODS
The primary comparison tested complete vs culprit revascularization. Timing and methods of achieving complete revascularization were assessed. The prespecified primary outcome was all-cause mortality. Outcomes were expressed as relative risk (RR) (95% 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, major adverse cardiac events and repeat revascularization were also significantly reduced. In patients presenting with ST-segment elevation myocardial infarction, 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
Complete revascularization following MI reduces all-cause mortality, cardiovascular mortality, MI, major adverse cardiac events, and repeat revascularization. There may be benefits to immediate complete revascularization, but additional head-to-head trials are needed.
Additional Info
Percutaneous Coronary Revascularization Strategies After Myocardial Infarction: A Systematic Review and Network Meta-Analysis
J Am Coll Cardiol 2024 Jul 16;84(3)276-294, RK Reddy, JP Howard, Y Jamil, MV Madhavan, MG Nanna, AJ Lansky, MB Leon, Y AhmadFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
There are multiple therapeutic strategies available to manage patients presenting with myocardial infarction (MI) and multivessel coronary artery disease. Revascularization can be limited to the culprit artery only, or complete revascularization of all significant coronary lesions can be performed. If complete revascularization is sought, it may be performed during the index procedure or later in a staged manner. Nonculprit lesions can be assessed for severity using either angiography or physiological measurements.
Prior observational studies suggested increased mortality risks associated with complete revascularization through multivessel PCI in the context of MI. Accordingly, international guidelines recommended that culprit-only revascularization be performed, except in cases of cardiogenic shock.1 However, subsequent evidence from randomized controlled trials over the past decade disproved these earlier observational findings, showing that complete revascularization reduced the risks of cardiovascular death and future MI.2 There has since been a reversal in guideline recommendations, with the previous class III recommendation for PCI of nonculprit lesions in hemodynamically stable patients now replaced by a class I recommendation.3
An all-cause mortality benefit has yet to be demonstrated, and questions remain regarding the optimal timing of complete revascularization (whether immediate or staged) as well as the method for evaluating nonculprit lesions (physiological assessment or angiography). In this context, the investigators conducted a systematic review and network meta-analysis of all available randomized data to assess the effect of complete revascularization (and methods of achieving it) on clinical endpoints compared with a culprit-only strategy.
Overall, 24 trials involving 16,371 patients were eligible for the analysis. Compared with culprit-only revascularization, complete revascularization was associated with a 15% reduction in the prespecified primary endpoint of all-cause mortality in a pairwise meta-analysis (RR, 0.85; 95% CI, 0.74–0.99; P = .04). Statistical heterogeneity was low (I2 = 7.1%). The risks of cardiovascular mortality, repeat MI, major adverse cardiovascular events, and repeat revascularization were also significantly reduced with a complete revascularization strategy, with no difference observed in the rates of acute kidney injury, major bleeding or stent thrombosis.
Meta-regression analyses revealed no differential treatment effect between patients with ST-segment elevation MI or non–ST-segment elevation MI (NSTEMI; Pinteraction = .24). The ongoing COMPLETE-2 (NCT05701358) and COMPLETE-NSTEMI (NCT05786131) trials are investigating the effects of complete revascularization in greater detail among patients with NSTEMI. Network meta-analyses suggested a potential benefit from achieving complete revascularization during the index procedure compared with a staged approach. However, whether angiographic or physiological assessment should guide nonculprit revascularization decisions remains unclear following the network meta-analyses. Further head-to-head randomized comparisons are required to definitively answer these questions.
The take-home message from this comprehensive analysis of randomized trial data is that complete revascularization with PCI reduces the risk of all-cause mortality and other important cardiovascular outcomes in patients with acute MI and multivessel coronary artery disease. No safety concerns were identified. Clinicians should focus on achieving complete revascularization by the safest possible method to reduce the risk of all-cause death and other adverse cardiovascular events.
References