title: Direct stenting versus pre-dilation in ST-elevation myocardial infarction: a systematic review and meta-analysis.
abstract: OBJECTIVE
  This study aimed at comparing direct stenting (DS) versus stenting with pre-dilation (SP) in patients with ST-elevation myocardial infarction (STEMI), using a systematic review and meta-analysis of published evidence.
  
  
  BACKGROUND
  There is conflicting evidence whether stenting strategy impacts clinical outcomes in patients with STEMI.
  
  
  METHODS
  We searched EMBASE, MEDLINE, and CENTRAL, from inception to December 2014. The primary endpoint was mortality. Secondary endpoints included major adverse cardiac events (MACEs), ST-segment resolution, and angiographic outcomes.
  
  
  RESULTS
  A total of 9,331 patients enrolled in 12 studies (3 randomized controlled trials, RCTs; 9 non-randomized studies, NRSs) were included. DS was associated with lower mortality (OR 0.55; 95%CI: 0.33-0.94; P = 0.03) in NRSs, and overall (OR 0.56; 95%CI: 0.37-0.86; P = 0.008). Mortality was non-significantly reduced in RCTs (OR 0.56; 95%CI: 0.26-1.23; P = 0.15). DS was also associated with lower MACE rate (OR 0.71; 95%CI 0.60-0.84; P < 0.0001) in NRSs, but not in RCTs (OR 0.99; 95%CI: 0.61-1.60; P = 0.96). ST-segment resolution, no reflow, final thrombolysis in myocardial infarction (TIMI) flow and final TIMI myocardial perfusion or blush grade were significantly better with DS in NRSs, and non-significantly better in RCTs.
  
  
  CONCLUSIONS
  The available evidence suggests that DS in STEMI might be associated with better clinical and procedural outcomes, as compared with SP. However, the fact that RCTs account for the minority of available data and that most of the available studies poorly reflect current clinical practice, as well as the existence of publication bias, preclude drawing definitive conclusions.
authors.affiliation: Interventional Cardiology Division, Department of Medicine, Montreal Heart Institute, Université de Montréal, Montréal, QC, Canada.
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Azzalini
authors.forename: Xavier
authors.initials: X
authors.lastname: Millán
authors.forename: Hung Q
authors.initials: HQ
authors.lastname: Ly
authors.forename: Philippe L
authors.initials: PL
authors.lastname: L'Allier
authors.forename: E Marc
authors.initials: EM
authors.lastname: Jolicoeur
mesh_terms: D001145:Arrhythmias, Cardiac; D053840:Brugada Syndrome; D000075224:Cardiac Conduction System Disease; D006329:Heart Conduction System / Q000002:abnormalities; D006801:Humans; D009203:Myocardial Infarction / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D062645:Percutaneous Coronary Intervention; D015607:Stents