Meta-Analysis Comparing Complete Versus Infarct-Related Artery Revascularization in Patients With ST-Elevation Myocardial Infarction and Multivessel Coronary Disease

Current recommendations for revascularization of non-infarct-related artery in patients presenting with ST-segment elevation myocardial infarction and multivessel disease

ST-segment elevation myocardial infarction (STEMI) is a leading cause of morbidity and mortality worldwide. Immediate reperfusion therapy of the infarct-related artery (IRA) is the mainstay of treatment, either via primary percutaneous coronary intervention (PPCI) or thrombolytic therapy when PPCI is not feasible. Several studies have reported the incidence of multivessel disease (MVD) to be about 50% of total STEMI cases. This means that after successful PPCI of the IRA, residual lesion(s) of the non-IRA may persist. Unlike the atherosclerotic plaque of stable coronary artery disease, the residual obstructive lesion of the non-IRA contains a significantly higher prevalence of vulnerable plaques. Since these lesions are a strong predictor of acute coronary syndrome, if left untreated they are a possible cause of future adverse cardiovascular events. Percutaneous coronary intervention (PCI) of the obstructive lesion of the non-IRA to achieve complete revascularization (CR) is therefore preferable. Several major randomized controlled trials (RCTs) and meta-analyses demonstrated the clinical benefits of the CR strategy in the setting of STEMI with MVD, not only for enhancing survival but also for reducing unplanned revascularization. The CR strategy is now supported by recently published clinical practice guidelines. Nevertheless, the benefit of revascularization must be weighed against the risks from additional procedures.

Therapeutic Potential of Exosomes Derived From circRNA_0002113 Lacking Mesenchymal Stem Cells in Myocardial Infarction

Exosomes are participated in the pathogenesis of cardiovascular diseases and can be secreted by mesenchymal stem cells (MSCs). However, the effects of circRNA, delivered by exosomes derived from MSCs, on myocardial injury remain unclear. Hence, this study aims to explore the therapeutic potential of exosomes derived from circRNA_0002113 lacking MSCs in the treatment of myocardial injury in vitro and in vivo. Our results reveal that exosomes derived from circRNA_0002113 lacking MSCs decreased cell apoptosis in anoxia-reoxygenation (A/R) model cells, and reduced myocardial injury by inhibiting nuclear translocation of RUNX1 in vitro and in vivo. Moreover, miR-188-3p, which targets RUNX1 in cardiomyocytes was also found to interact with circRNA_0002113. In conclusion, exosomes derived from circRNA_0002113 lacking MSCs could suppress myocardial infarction by sponging miR-188-3p to regulate RUNX1 nuclear translocation. The circRNA_0002113/miR-188-3p/RUNX1 axis mediated alleviation of apoptosis serves as a novel strategy to treat myocardial I/R injury.

Comprehensive Review of Complete Versus Culprit-only Revascularization for Multivessel Disease in ST-segment Elevation Myocardial Infarction

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Multivessel versus culprit-only PCI in STEMI patients with multivessel disease: meta-analysis of randomized controlled trials

AIMS

To perform a pairwise meta-analysis of randomized controlled trials (RCTs) comparing multivessel percutaneous coronary intervention (PCI) and culprit vessel-only PCI in ST-elevation myocardial infarction (STEMI) patients without cardiogenic shock.

METHODS

We searched MEDLINE, Cochrane Central Register of Controlled Trials, and Embase for RCTs comparing multivessel PCI with culprit vessel-only PCI in STEMI patients without cardiogenic shock and multivessel coronary artery disease. Only RCTs reporting mortality or myocardial reinfarction after at least 6 months following randomization were included. Hazard ratios (HRs) were pooled using random-effect models.

RESULTS

Nine RCTs were included in the final analysis. In total, 523 (8.3%) of 6314 patients suffered the combined primary endpoint of death or non-fatal reinfarction. This primary endpoint was significantly reduced with multivessel PCI compared to culprit vessel-only PCI (HR 0.63, 95% confidence interval [CI] 0.43-0.93; p = 0.03). This finding was driven by a reduction of non-fatal reinfarction (HR 0.64, 95% CI 0.52-0.79; p = 0.001), whereas no significant reduction of all-cause death (HR 0.77, 95% CI 0.44-1.35; p = 0.28) or cardiovascular death (HR 0.64, 95% CI 0.37-1.11; p = 0.09) was observed.

CONCLUSIONS

In STEMI patients without cardiogenic shock multivessel PCI reduced the risk of death or non-fatal reinfarction compared to culprit vessel-only PCI.

Complete Versus Culprit-Only Revascularization in Patients Presenting With ST-Segment Elevation Myocardial Infarction: A Meta-Analysis of Randomized Control Trials

BACKGROUND

In patients with ST elevation myocardial infarction (STEMI), primary percutaneous coronary intervention (PCI) of the culprit vessel is the preferred treatment option. For patients with multivessel disease, the benefit of revascularization of the non-culprit artery is not well known. This meta-analysis aims to assess the efficacy and safety of complete versus culprit vessel only revascularization.

METHODS

Randomized control trials (RCT) that compared head-to-head complete versus culprit-vessel only revascularization in STEMI patients and reported main outcomes of interest such as mortality, myocardial infarction, and revascularization, were included in this meta-analysis.

RESULTS

We found ten RCTs satisfying our inclusion criteria. Data was extracted and used to estimate the risk ratio (RR) and 95% confidence interval (CI) for dichotomous variables. Our study included 7030 patients (3426 complete revascularization, and 3604 culprit-only revascularization). Complete revascularization (CR) (both immediate and staged) significantly reduced the risk of MACE compared with culprit only (CO) revascularization (10.7% vs 20.1%, RR 0.53; 95% CI 0.43 to 0.64; P < 0.0001), reinfarction (5.0% vs 6.9%, RR 0.69; 95 CI 0.51 to 0.93; P < 0.01), and revascularization (4.2% vs 12.7%, RR 0.37; 95 CI 0.26 to 0.54; P < 0.0001). Our analysis did not find any significant difference in all-cause mortality between CR and CO (4.6% vs 5.0%, RR 0.89; 95 CI 0.72 to 0.1.10; P = 0.27).

CONCLUSION

In conclusion, complete revascularization was associated with a significant reduction in major adverse cardiovascular events, revascularization and reinfarction.

Complete Revascularization in Patients With STEMI and Multi-Vessel Disease: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Percutaneous coronary intervention (PCI) is the treatment of choice for ST-elevation myocardial infarction (STEMI). However, efficacy of complete vs culprit only revascularization in patients with STEMI and multivessel disease remains unclear.

METHODS

We searched PubMed/MEDLINE, and Cochrane library. The primary endpoint was major adverse cardiovascular events (MACE). Secondary outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction (MI), repeat revascularization, stroke, major bleeding, and contrast induced nephropathy. Estimates were calculated as random effects hazard ratios (HRs) with 95% confidence intervals (CI).

RESULTS

Twelve trials with 7592 patients were included. There was a significantly lower risk of MACE [HR 0.61; 95% CI (0.43-0.60); p = 0.0009; I² = 72%], cardiovascular mortality [HR 0.74; 95% CI (0.56-0.99); p = 0.04; I² = 2%], and repeat revascularization [HR 0.43; 95% CI (0.31-0.59); p < 0.00001; I² = 67%] in patients treated with complete compared with culprit-only revascularization. There was no statistically significant difference in MI [HR 0.77; 95% CI (0.52-1.12); p = 0.17; I² = 49%], all-cause mortality [HR 0.86; 95% CI (0.65-1.13); p = 0.28; I² = 14%], heart failure [HR 0.82 95% CI (0.51-1.32); p = 0.42; I² = 26%], major bleeding [HR 1.07; 95% CI (0.66-1.75); p = 0.78; I² = 25%], stroke [HR 0.67; 95% CI (0.24-1.89); p = 0.45; I² = 54%], or contrast induced nephropathy, although higher contrast volumes were used in the complete revascularization group [HR 1.22; 95% CI (0.78-1.92); p = 0.39; I² = 0%].

CONCLUSION

Complete revascularization was associated with a significantly lower risk of MACE, cardiovascular mortality, and repeat revascularization compared with culprit-only revascularization. These results suggest complete revascularization with PCI following STEMI and multivessel disease should be considered.