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Akbari T, Al-Lamee R. Percutaneous coronary intervention in multi-vessel disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 44:80-91. [DOI: 10.1016/j.carrev.2022.06.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 01/09/2023]
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Meta-Analysis of Culprit-Only Versus Multivessel Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Disease. Am J Cardiol 2018; 121:529-536. [PMID: 29304995 DOI: 10.1016/j.amjcard.2017.11.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 11/09/2017] [Accepted: 11/13/2017] [Indexed: 01/10/2023]
Abstract
Recently, several randomized controlled trials (RCT) in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) have compared a strategy of routine multivessel percutaneous coronary intervention (PCI) performed either as a single procedure or as staged procedures to culprit-only PCI. All of these trials have been underpowered for clinical end points. We searched PubMed, Embase, and Cochrane Central Register of Controlled Trials for RCT comparing multivessel PCI with culprit-only PCI in patients with STEMI and MVD. The primary efficacy outcome was the composite rate of death or MI. Other efficacy outcomes included death, MI, and repeat revascularization. Safety outcomes were contrast-associated acute kidney injury, stroke, and major bleeding. Pairwise direct comparison and mixed-treatment comparison network meta-analyses were performed. Eleven trials that enrolled 3,150 patients with a total of 5,296 patient-years of follow-up were included. In direct comparison meta-analysis, single-procedure multivessel PCI was associated with a reduction in the risk of death or MI (rate ratio [RR] = 0.52; 95% confidence interval [CI] 0.37 to 0.73; p <0.001), due to less death (RR = 0.64; 95% CI 0.40 to 1.02; p = 0.06) and MI (RR = 0.42; 95% CI 0.25 to 0.69; p <0.0001) compared with culprit-only PCI. No heterogeneity (I2 = 0) was present between studies. In contrast, staged multivessel PCI did not significantly reduce death or MI compared with culprit-only PCI. Both multivessel PCI strategies reduced the risk of repeat revascularization without significant differences in safety outcomes. Results were consistent in the mixed-treatment comparison meta-analysis. In conclusion, the present meta-analysis suggests that single-procedure multivessel PCI may be the preferred strategy in patients with STEMI and MVD.
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Nguyen AV, Thanh LV, Kamel MG, Abdelrahman SAM, EL-Mekawy M, Mokhtar MA, Ali AA, Hoang NNN, Vuong NL, Abd-Elhay FAE, Omer OA, Mohamed AA, Hirayama K, Huy NT. Optimal percutaneous coronary intervention in patients with ST-elevation myocardial infarction and multivessel disease: An updated, large-scale systematic review and meta-analysis. Int J Cardiol 2017. [DOI: 10.1016/j.ijcard.2017.06.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Patel S, Bailey SR. Revascularization Strategies in STEMI with Multivessel Disease: Deciding on Culprit Versus Complete-Ad Hoc or Staged. Curr Cardiol Rep 2017; 19:93. [PMID: 28840487 DOI: 10.1007/s11886-017-0906-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW This review will address the clinical conundrum of those who may derive clinical benefit from complete revascularization of coronary stenosis that are discovered at the time of ST segment elevation myocardial infarction (STEMI). The decision to revascularize additional vessels with angiographic stenosis beyond the culprit lesion remains controversial, as does the timing of revascularization. RECENT FINDINGS STEMI patients represent a high-risk patient population that have up to a 50% prevalence of multivessel disease. Multivessel disease represents an important risk factor for short- and long-term morbidity and mortality. Potential benefits of multivessel PCI for STEMI might include reduced short- and long-term mortality, revascularization, reduced resource utilization, and costs. Which population will benefit and what the optimal timing of revascularization in the peri-MI period remains controversial. Consideration of multivessel revascularization in the setting of STEMI may occur in up to one half of STEMI patients. Evaluation of the comorbidities including diabetes, extent of myocardium at risk, lesion complexity, ventricular function, and risk factors for complications such as contrast induced nephropathy which is important in determining the appropriate care pathway.
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Affiliation(s)
- Shalin Patel
- From the Janey Briscoe Center of Excellence for Cardiovascular Research, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78232, USA
| | - Steven R Bailey
- From the Janey Briscoe Center of Excellence for Cardiovascular Research, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78232, USA.
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Vogel B, Mehta SR, Mehran R. Reperfusion strategies in acute myocardial infarction and multivessel disease. Nat Rev Cardiol 2017; 14:665-678. [DOI: 10.1038/nrcardio.2017.88] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Cubero-Gallego H, Romaguera R, Ariza-Sole A, Gómez-Hospital JA, Cequier A. Revascularization strategies in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease: urgent or staged? Cardiovasc Diagn Ther 2017; 7:S82-S85. [PMID: 28748154 DOI: 10.21037/cdt.2017.01.15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Héctor Cubero-Gallego
- Heart Diseases Institute, Hospital de Bellvitge - IDIBELL, University of Barcelona, Barcelona, Spain
| | - Rafael Romaguera
- Heart Diseases Institute, Hospital de Bellvitge - IDIBELL, University of Barcelona, Barcelona, Spain
| | - Albert Ariza-Sole
- Heart Diseases Institute, Hospital de Bellvitge - IDIBELL, University of Barcelona, Barcelona, Spain
| | | | - Angel Cequier
- Heart Diseases Institute, Hospital de Bellvitge - IDIBELL, University of Barcelona, Barcelona, Spain
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Iqbal MB, Nadra IJ, Ding L, Fung A, Aymong E, Chan AW, Hodge S, Della Siega A, Robinson SD. Culprit Vessel Versus Multivessel Versus In-Hospital Staged Intervention for Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Disease. JACC Cardiovasc Interv 2017; 10:11-23. [DOI: 10.1016/j.jcin.2016.10.024] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 10/03/2016] [Accepted: 10/20/2016] [Indexed: 11/26/2022]
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Nagaraja V, Ooi SY, Nolan J, Large A, De Belder M, Ludman P, Bagur R, Curzen N, Matsukage T, Yoshimachi F, Kwok CS, Berry C, Mamas MA. Impact of Incomplete Percutaneous Revascularization in Patients With Multivessel Coronary Artery Disease: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2016; 5:JAHA.116.004598. [PMID: 27986755 PMCID: PMC5210416 DOI: 10.1161/jaha.116.004598] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Up to half of patients undergoing percutaneous coronary intervention have multivessel coronary artery disease (MVD) with conflicting data regarding optimal revascularization strategy in such patients. This paper assesses the evidence for complete revascularization (CR) versus incomplete revascularization in patients undergoing percutaneous coronary intervention, and its prognostic impact using meta‐analysis. Methods and Results A search of PubMed, EMBASE, MEDLINE, Current Contents Connect, Google Scholar, Cochrane library, Science Direct, and Web of Science was conducted to identify the association of CR in patients with multivessel coronary artery disease undergoing percutaneous coronary intervention with major adverse cardiac events and mortality. Random‐effects meta‐analysis was used to estimate the odds of adverse outcomes. Meta‐regression analysis was conducted to assess the relationship with continuous variables and outcomes. Thirty‐eight publications that included 156 240 patients were identified. Odds of death (OR 0.69, 95% CI 0.61‐0.78), repeat revascularization (OR 0.60, 95% CI 0.45‐0.80), myocardial infarction (OR 0.64, 95% CI 0.50‐0.81), and major adverse cardiac events (OR 0.63, 95% CI 0.50‐0.79) were significantly lower in the patients who underwent CR. These outcomes were unchanged on subgroup analysis regardless of the definition of CR. Similar findings were recorded when CR was studied in the chronic total occlusion (CTO) subgroup (OR 0.65, 95% CI 0.53‐0.80). A meta‐regression analysis revealed a negative relationship between the OR for mortality and the percentage of CR. Conclusion CR is associated with reduced risk of mortality and major adverse cardiac events, irrespective of whether an anatomical or a score‐based definition of incomplete revascularization is used, and this magnitude of risk relates to degree of CR. These results have important implications for the interventional management of patients with multivessel coronary artery disease.
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Affiliation(s)
- Vinayak Nagaraja
- Department of Cardiology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Sze-Yuan Ooi
- Department of Cardiology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - James Nolan
- Royal Stoke University Hospital, University Hospitals of North Midlands, Stoke-on-Trent, United Kingdom.,Keele Cardiovascular Research Group, Institute of Science and Technology in Medicine, University of Keele, Stoke-on-Trent, United Kingdom
| | - Adrian Large
- Royal Stoke University Hospital, University Hospitals of North Midlands, Stoke-on-Trent, United Kingdom
| | - Mark De Belder
- The James Cook University Hospital, Middlesbrough, United Kingdom
| | - Peter Ludman
- Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Rodrigo Bagur
- Division of Cardiology, Department of Medicine and Department of Epidemiology & Biostatistics, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Nick Curzen
- University Hospital Southampton & Faculty of Medicine University of Southampton, United Kingdom
| | - Takashi Matsukage
- Division of Cardiology, Tokai University School of Medicine, Isehara, Japan
| | | | - Chun Shing Kwok
- Royal Stoke University Hospital, University Hospitals of North Midlands, Stoke-on-Trent, United Kingdom.,Keele Cardiovascular Research Group, Institute of Science and Technology in Medicine, University of Keele, Stoke-on-Trent, United Kingdom
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom
| | - Mamas A Mamas
- Royal Stoke University Hospital, University Hospitals of North Midlands, Stoke-on-Trent, United Kingdom .,Keele Cardiovascular Research Group, Institute of Science and Technology in Medicine, University of Keele, Stoke-on-Trent, United Kingdom
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Meta-Analysis Comparing Complete Revascularization Versus Infarct-Related Only Strategies for Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Artery Disease. Am J Cardiol 2016; 118:1466-1472. [PMID: 27642115 DOI: 10.1016/j.amjcard.2016.08.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 08/09/2016] [Accepted: 08/09/2016] [Indexed: 01/01/2023]
Abstract
Several recent randomized controlled trials (RCTs) demonstrated better outcomes with multivessel complete revascularization (CR) than with infarct-related artery-only revascularization (IRA-OR) in patients with ST-segment elevation myocardial infarction. It is unclear whether CR should be performed during the index procedure (IP) at the time of primary percutaneous coronary intervention (PCI) or as a staged procedure (SP). Therefore, we performed a pairwise meta-analysis using a random-effects model and network meta-analysis using mixed-treatment comparison models to compare the efficacies of 3 revascularization strategies (IRA-OR, CR-IP, and CR-SP). Scientific databases and websites were searched to find RCTs. Data from 9 RCTs involving 2,176 patients were included. In mixed-comparison models, CR-IP decreased the risk of major adverse cardiac events (MACEs; odds ratio [OR] 0.36, 95% CI 0.25 to 0.54), recurrent myocardial infarction (MI; OR 0.50, 95% CI 0.24 to 0.91), revascularization (OR 0.24, 95% CI 0.15 to 0.38), and cardiovascular (CV) mortality (OR 0.44, 95% CI 0.20 to 0.87). However, only the rates of MACEs, MI, and CV mortality were lower with CR-SP than with IRA-OR. Similarly, in direct-comparison meta-analysis, the risk of MI was 66% lower with CR-IP than with IRA-OR, but this advantage was not seen with CR-SP. There were no differences in all-cause mortality between the 3 revascularization strategies. In conclusion, this meta-analysis shows that in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease, CR either during primary PCI or as an SP results in lower occurrences of MACE, revascularization, and CV mortality than IRA-OR. CR performed during primary PCI also results in lower rates of recurrent MI and seems the most efficacious revascularization strategy of the 3.
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Bates ER, Tamis-Holland JE, Bittl JA, O’Gara PT, Levine GN. PCI Strategies in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Artery Disease. J Am Coll Cardiol 2016; 68:1066-81. [DOI: 10.1016/j.jacc.2016.05.086] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/19/2016] [Accepted: 05/10/2016] [Indexed: 12/19/2022]
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Managing Multivessel Coronary Artery Disease in Patients With ST-Elevation Myocardial Infarction: A Comprehensive Review. Cardiol Rev 2016; 25:179-188. [PMID: 27124268 DOI: 10.1097/crd.0000000000000110] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Multivessel coronary artery disease (CAD) is found in up to 60% of the patients presenting with an ST-elevation myocardial infarction (STEMI) and worsens the prognosis proportional to the extent of CAD severity. However, the 2013 American College of Cardiology/American Heart Association STEMI guidelines, based on mostly observational data, had recommended against a routine noninfarct-related artery percutaneous coronary intervention (PCI). After these guidelines were published, a handful of randomized trials became available, and they suggested that PCI of significant lesions in a noninfarct-related artery at the time of primary PCI might result in improved patient outcomes. The incidence of major adverse cardiac events was significantly reduced by 55% at 1 year and 65% at 2 years in patients undergoing angiographically guided PCI of nonculprit vessels at the time of primary PCI, in 2 different randomized trials. Fractional flow reserve-guided PCI of nonculprit vessels in this setting has also been shown to reduce cardiac events by 44% at 1 year. Meta-analyses of both nonrandomized and randomized trials have also suggested that complete revascularization at the time of STEMI significantly improves outcomes, including long-term all-cause mortality. In view of the emerging data, a focused update on primary PCI was published in 2015 and suggested that PCI of noninfarct-related arteries might be considered in selected patients. This article is a comprehensive review of the literature on the treatment of multivessel CAD in patients with STEMI, which provides the reader a critical analysis of the available information to determine the best therapeutic approach.
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