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Original Investigation
May 20, 2020

Complete vs Culprit-Lesion-Only Revascularization for ST-Segment Elevation Myocardial Infarction: A Systematic Review and Meta-analysis

Author Affiliations
  • 1Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
  • 2The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
  • 3Department of Cardiology, Maasstad Ziekenhuis, Rotterdam, the Netherlands
  • 4Department of Cardiovascular Sciences, University of Leicester and NIHR (National Institute of Heath Research) Leicester Cardiovascular Biomedical Research Unit, University Hospitals of Leicester NHS (National Health Service) Trust, Glenfield Hospital, Leicester, United Kingdom
  • 5Department of Medical Sciences, Uppsala University, Uppsala, Sweden
  • 6Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
  • 7Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
  • 8Zena and Michael A. Weiner Cardiovascular Institute, Mount Sinai School of Medicine, New York, New York
  • 9Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
  • 10Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
JAMA Cardiol. Published online May 20, 2020. doi:10.1001/jamacardio.2020.1251
Key Points

Question  Compared with a culprit-lesion-only percutaneous coronary intervention strategy, is a strategy of complete revascularization with multivessel percutaneous coronary intervention associated with decreased cardiovascular mortality in ST-segment elevation myocardial infarction, and what is the association when fractional flow reserve– and angiography-guided complete revascularization approaches are used?

Findings  In this systematic review and meta-analysis of 10 randomized clinical trials of 7030 unique patients, a 31% relative risk reduction in cardiovascular death (no significant reduction in all-cause mortality) was associated with a complete revascularization strategy. Consistent associations were found when a fractional flow reserve– or angiography-guided complete revascularization approach was used.

Meaning  These results potentially extend the benefit of a complete revascularization strategy to include a reduction in cardiovascular mortality with a consistent benefit of a fractional flow reserve– or angiography-guided percutaneous coronary intervention approach on hard clinical events.

Abstract

Importance  Recently, the Complete vs Culprit-Only Revascularization to Treat Multivessel Disease After Early PCI (percutaneous coronary intervention) for STEMI (ST-segment elevation myocardial infarction [MI]) (COMPLETE) trial showed that angiography-guided PCI of the nonculprit lesion with the goal of complete revascularization reduced cardiovascular (CV) death or new MI compared with PCI of the culprit lesion only in STEMI. Whether complete revascularization also reduces CV mortality is uncertain. Moreover, whether the association of complete revascularization with hard clinical outcomes is consistent when fractional flow reserve (FFR)– and angiography-guided strategies are used is unknown.

Objective  To determine through a systematic review and meta-analysis (1) whether complete revascularization is associated with decreased CV mortality and (2) whether heterogeneity in the association occurs when FFR- and angiography-guided PCI strategies for nonculprit lesions are performed.

Data Sources  A systematic search of MEDLINE, Embase, ISI Web of Science, and CENTRAL (Cochrane Central Register of Controlled Trials) from database inception to September 30, 2019, was performed. Conference proceedings were also reviewed from January 1, 2002, to September 30, 2019.

Study Selection  English-language randomized clinical trials comparing complete revascularization vs culprit-lesion-only PCI in patients with STEMI and multivessel disease were included.

Data Extraction and Synthesis  The combined odds ratio (OR) was calculated with the random-effects model using the Mantel-Haenszel method (sensitivity with fixed-effects model). Heterogeneity was measured using the I2 statistic. Publication bias was evaluated using the inverted funnel plot approach. Data were analyzed from October 2019 to January 2020.

Main Outcomes and Measures  Cardiovascular death and the composite of CV death or new MI.

Results  Ten randomized clinical trials involving 7030 unique patients were included. The weighted mean follow-up time was 29.5 months. Complete revascularization was associated with reduced CV death compared with culprit-lesion-only PCI (80 of 3191 [2.5%] vs 106 of 3406 [3.1%]; OR, 0.69 [95% CI, 0.48-0.99]; P = .05; fixed-effects model OR, 0.74 [95% CI, 0.55-0.99]; P = .04). All-cause mortality occurred in 153 of 3426 patients (4.5%) in the complete revascularization group vs 177 of 3604 (4.9%) in the culprit-lesion-only group (OR, 0.84 [95% CI, 0.67-1.05]; P = .13; I2 = 0%). Complete revascularization was associated with a reduced composite of CV death or new MI (192 of 2616 [7.3%] vs 266 of 2586 [10.3%]; OR, 0.69 [95% CI, 0.55-0.87]; P = .001; fixed-effects model OR, 0.69 [95% CI, 0.57-0.84]; P < .001), with no heterogeneity in this outcome when complete revascularization was performed using an FFR-guided strategy (OR, 0.78 [95% CI, 0.43-1.44]) or an angiography-guided strategy (OR, 0.61 [95% CI, 0.38-0.97]; P = .52 for interaction).

Conclusions and Relevance  In patients with STEMI and multivessel disease, complete revascularization was associated with a reduction in CV mortality compared with culprit-lesion-only PCI. There was no differential association with treatment between FFR- and angiography-guided strategies on major CV outcomes.

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