title: What is the optimal approach to a non- culprit stenosis after ST-elevation myocardial infarction - Conservative therapy or upfront revascularization? An updated meta-analysis of randomized trials.
abstract: BACKGROUND
  Non-culprit percutaneous coronary intervention (PCI) during a ST-segment elevation myocardial infarction (STEMI) remains controversial. We performed a meta-analysis of the published literature comparing a strategy of complete revascularization (CR) with culprit or target vessel revascularization (TVR)-only after STEMI in patients with multi-vessel disease.
  
  
  METHODS
  We searched PubMed/Medline, Cochrane, EMBASE, Web of Science, CINAHL, Scopus and Google-scholar databases from inception to March-2016 for clinical trials comparing CR with TVR during PCI for STEMI. Mantel-Haenszel risk ratio (MH-RR) with 95% confidence intervals (CI) for individual outcomes was calculated using random-effects model.
  
  
  RESULTS
  A total of 7 randomized trials with 2004 patients were included in the final analysis. Mean follow-up was 25.4months. Major adverse cardiac events (MACE) (MH-RR: 0.58, 95% CI: 0.43-0.78, P<0.001), cardiac deaths (MH-RR: 0.42, 95% CI: 0.24-0.74, P=0.003) and repeat revascularization (MH-RR: 0.36, 95% CI: 0.27-0.48, P<0.001) were much lower in the CR group when compared to TVR. However, there was no significant difference in the risk of all-cause mortality (0.84, 95% CI: 0.57-1.25, P=0.394) or recurrent MI (MH-RR: 0.66, 95% CI: 0.34-1.26, P=0.205) between the two groups. CR appeared to be safe with no significant increase in adverse events including stroke rates (MH-RR: 2.19, 95% CI: 0.59-8.12, P=0.241), contrast induced nephropathy (MH-RR: 0.73, 95% CI: 0.34-1.57, P=0.423) or major bleeding episodes (MH-RR: 0.72, 95% CI: 0.34-1.54, P=0.399).
  
  
  CONCLUSIONS
  CR strategy in STEMI patients with multivessel coronary artery disease is associated with reduction in MACE, cardiac mortality and need for repeat revascularization but with no decrease in the risk of subsequent MI or all-cause mortality. CR was safe however, with no increase in adverse events including stroke, stent thrombosis or contrast nephropathy when compared to TVR.
authors.affiliation: Department of Internal Medicine, Creighton University School of Medicine, Omaha, NE, USA. Electronic address: mahesh_maidsh@yahoo.com.
authors.forename: Mahesh
authors.initials: M
authors.lastname: Anantha Narayanan
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
authors.forename: Yogesh N V
authors.initials: YN
authors.lastname: Reddy
authors.affiliation: Division of Cardiovascular Diseases, University Hospitals Case Medical Center, Cleveland, OH, USA.
authors.forename: Varun
authors.initials: V
authors.lastname: Sundaram
authors.affiliation: Department of Internal Medicine, Boston University Medical Center, Boston, MA, USA.
authors.forename: Yuvaram N V
authors.initials: YN
authors.lastname: Reddy
authors.affiliation: Sri Venkateshwaraa Medical College Hospital and Research Center, Puducherry, India.
authors.forename: Janani
authors.initials: J
authors.lastname: Baskaran
authors.affiliation: Department of Internal Medicine, Saint Peters University Hospital, New Brunswick, NJ, USA.
authors.forename: Kanishk
authors.initials: K
authors.lastname: Agnihotri
authors.affiliation: Department of Cardiology, The Everett Clinic, Everett, WA, USA.
authors.forename: Apurva
authors.initials: A
authors.lastname: Badheka
authors.affiliation: Department of Cardiology, University of Miami Miller School of Medicine, Miami, FL, USA.
authors.forename: Nilesh
authors.initials: N
authors.lastname: Patel
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
authors.forename: Abhishek
authors.initials: A
authors.lastname: Deshmukh
mesh_terms: D000072700:Conservative Treatment / Q000379:methods*; D003324:Coronary Artery Disease / Q000601:surgery*; D006801:Humans; D062645:Percutaneous Coronary Intervention / Q000379:methods*; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D000072657:ST Elevation Myocardial Infarction / Q000601:surgery*; D016896:Treatment Outcome
keywords: Major adverse cardiac events; Multi-vessel coronary artery disease; Primary percutaneous coronary intervention; Revascularization; ST-elevation myocardial infarction