Infarct related artery only versus complete revascularization in ST-segment elevation myocardial infarction and multi vessel disease: a meta-analysis.
BACKGROUND
The 2015 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) focused update on primary percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) only gives a class II b (weak) indication for non-infarct artery intervention at the time of primary PCI. Recent randomized controlled trials, however, suggest strong evidence supporting complete revascularization.


METHODS
A systematic search was conducted in PUBMED, MEDLINE, EMBASE and Cochrane central register for randomized controlled trials comparing complete versus infarct artery (IRA) only revascularization in patients with STEMI. A meta-analysis was performed using the data extracted from each study. Summary risk ratios (RR) and 95% confidence intervals (CI) were calculated for five outcomes.


RESULTS
Six trials fulfilled the inclusion criteria yielding 1,792 patients. Follow up ranged from 6 months to 2.5 years. The incidence of major adverse cardiac events (MACE) was significantly lower in the complete revascularization group compared to the IRA only revascularization (13.8%vs. 25.1%, RR =0.51; 95% CI: 0.41-0.64, P<0.00001). It was attributed to significantly lower repeat revascularization rate in the complete revascularization group (8.2%vs. 18.9%, RR =0.41; 95% CI: 0.31-0.54, P<0.00001). This meta-analysis also showed a significant reduction in cardiovascular mortality (2.0%vs. 4.6%, RR =0.42; 95% CI: 0.24-0.74; P=0.003), non-fatal myocardial infarction (4.37%vs. 5.76%, RR =0.64; 95% CI: 0.34-1.20; P=0.16) and all-cause mortality rates [(4.6%vs. 6%), RR =0.75; 95% CI: 0.49-1.14, P=0.17] in the complete revascularization group, compared to the IRA revascularization group.


CONCLUSIONS
In patients who present with STEMI, complete revascularization is associated with lower rates of MACE and cardiovascular deaths as compared to revascularization of the IRA alone. Even though the outcomes of all-cause mortality and nonfatal re-infarction rates were lower in the complete revascularization group, they were not significant.
Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, USA.
Satyanarayana R
SR
Vaidya
Division of Cardiology, Cape Fear Valley Medical Center, Fayetteville, NC, USA;; Division of Cardiology, New York Methodist Hospital, Weill Cornell Medical College, NY, USA.
Santhosh R
SR
Devarapally
Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, USA;; Division of Cardiology, University of North Carolina at Chapel Hill, NC, USA.
Sameer
S
Arora
Complete revascularization; Infarct related artery: ST-segment elevation myocardial infarction (STEMI); culprit vessel