Updated Meta-Analysis Studies Complete Versus Culprit-Only Revascularization

October 24, 2016—Complete revascularization of all significant coronary lesions at the time of primarypercutaneous coronary intervention (PCI) compared with culprit-only revascularization is associated with a reduction in the risk of major adverse cardiovascular events (MACEs) because of a reduction in the risk of urgent revascularization; this approach appears to be safe, with no excess major bleeding or contrast-induced nephropathy, concluded Islam Y. Elgendy, MD, et al in Catheterization and Cardiovascular Intervention (2016;88:501–505).

This updated meta-analysis sought to determine which approach would be associated with better outcomes. The background of the study is that individual trials have demonstrated conflicting evidence regarding the optimum revascularization strategy at the time of primary PCI.

As summarized in Catheterization and Cardiovascular Intervention, the investigators evaluated seven clinical trials that randomized 1,939 ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease to a complete versus culprit-only revascularization strategy. Using a DerSimonian-Laird model, they constructed a random effects summary risk ratios. The primary outcome of interest was mortality or myocardial infarction (MI).

The investigators found that complete revascularization, compared with culprit-only revascularization, was associated with a nonsignificant reduction in the risk of mortality or MI (relative risk [RR], 0.69; 95% confidence interval [CI], 0.42–1.12; P = 0.14). Complete revascularization was associated with a reduced risk of MACEs (RR, 0.61; 95% CI, 0.45–0.81; P < .001), caused by a significant reduction in urgent revascularization (RR 0.46; 95% CI, 0.29–0.7; P < .001). The risk of major bleeding and contrast-induced nephropathy was similar either approach (RR, 0.83; 95% CI, 0.41–1.71; P = .62; and RR, 0.94; 95% CI, 0.42–2.12; P = .82), reported Dr. Elgendy and colleagues.

An accompanying editorial regarding these findings was published in Catheterization and Cardiovascular Intervention by Robert D. Safian, MD (2016;88:506–507). In the article titled, “The Third Rail of Interventional Cardiology: Revascularization of Non-Infarct–Related Arteries During Primary PCI,” Dr. Safian stated that despite current guidelines, there is expanding evidence for the safety and efficacy of routine multivessel PCI for STEMI patients. He also noted that fractional flow reserve has incremental value for assessing stenosis severity in STEMI patients with multivessel disease. Further studies of vulnerable plaque are needed to obtain a complete risk assessment for STEMI patients, advised Dr. Safian.