title: Complete vs Culprit-Only Percutaneous Coronary Intervention in STEMI With Multivessel Disease: A Meta-analysis and Trial Sequential Analysis of Randomized Trials.
abstract: Patients with ST-elevation myocardial infarction (STEMI) and multivessel disease (MVD) most commonly are treated with culprit-only percutaneous coronary intervention (PCI). However, this has been recently challenged, suggesting benefit with complete revascularization (CR). Still, these latest findings are largely based on clinical trials powered for composite outcomes that frequently include "softer" end points. We performed a meta-analysis comparing routine culprit-only PCI vs CR in STEMI, with an emphasis on "hard" clinical end points.
  
  
  
  MEDLINE, EMBASE, ISI Web of Science, and CENTRAL were searched from 1996-May 2015. Studies included patients with STEMI and MVD who received primary PCI. The primary end point was long-term death/myocardial infarction (MI). Data were combined using a fixed-effects model.
  
  
  
  Seven randomized trials (2004 patients: 1065 CR and 939 culprit-only PCI procedures) were included. Compared with culprit-only PCI, CR reduced the composite of death/MI (odds ratio [OR], 0.71; 95% confidence interval [CI], 0.52-0.96) but not death (OR, 0.78; 95% CI, 0.53-1.15) or recurrent MI (OR, 0.85; 95% CI, 0.58-1.24) alone. If CR was performed during the index catheterization, a reduction in death/MI was observed (death/MI: OR, 0.41; 95% CI, 0.25-0.65; death: OR, 0.59; 95% CI, 0.34-1.00; recurrent MI: OR, 0.35; 95% CI, 0.18-0.69). If staged, no benefits were noted (death/MI: OR, 0.99; 95% CI, 0.67-1.45; death: OR, 0.95; 95% CI, 0.56-1.61; recurrent MI: OR, 1.02; 95% CI, 0.61-1.70). However, when trial sequential analysis was performed for the overall population, the cumulative z-curve did not cross the monitoring boundary, suggesting a lack of evidence for reducing death/MI with CR (similar for index catheterization).
  
  
  
  In STEMI with MVD, there is insufficient evidence to support a reduction in death/MI with CR. Our results reinforce the need for larger clinical trials powered for robust clinical end points.
authors.affiliation: Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada. Electronic address: kevin.bainey@ualbertahealthservices.ca.
authors.forename: Kevin R
authors.initials: KR
authors.lastname: Bainey
authors.affiliation: Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Robert C
authors.initials: RC
authors.lastname: Welsh
authors.affiliation: Division of Cardiology, New York University School of Medicine, New York, New York, USA.
authors.forename: Bora
authors.initials: B
authors.lastname: Toklu
authors.affiliation: Division of Cardiology, New York University School of Medicine, New York, New York, USA.
authors.forename: Sripal
authors.initials: S
authors.lastname: Bangalore
mesh_terms: D003324:Coronary Artery Disease / Q000150:complications / Q000175:diagnosis; D006801:Humans; D010043:Outcome and Process Assessment, Health Care; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000379:methods; D016032:Randomized Controlled Trials as Topic; D000072657:ST Elevation Myocardial Infarction / Q000175:diagnosis / Q000209:etiology / Q000601:surgery; D055502:Secondary Prevention; D012720:Severity of Illness Index