Abstract
Complete versus culprit‐only revascularization in acute ST‐elevation myocardial infarction (STEMI) patients with multivessel disease is controversial. Current guidelines recommend treatment of the culprit artery alone during the primary procedure. However, with improvements in stent technique and with the use of new antiplatelet drugs (GP IIb/IIIa inhibitors), complete revascularization (CR) at an early stage is attracting increasing attention. We conducted an English language search on Medline (PubMed database), Embase, and the Cochrane databases between January 1966 and January 2011, as well as a search on the China National Knowledge Internet (1979–January 2011), and the Chinese Biomedical Literature Database (1978–January 2011). Randomized controlled trials (RCTs) or non‐RCTs that compared the two strategies in patients with STEMI and multivessel disease (MVD) during primary percutaneous coronary intervention (PCI) were included. Thirteen articles were selected, 8240 patients in the CR group and 51,998 in the culprit‐only revascularization group. CR was associated with an increased short‐term mortality [odds ratio (OR) = 1.39, 95% confidence interval (CI) = (1.26, 1.53)], a long‐term mortality [OR = 1.35, 95% CI = (1.09, 1.67)], and an increased risk of renal failure [OR (95% CI) = 1.24 (1.11, 1.38)] in patients with STEMI and MVD at the primary procedure. In addition, CR did not reduce the rate of short‐term major adverse cardiac events [OR (95% CI) = 1.52 (0.88, 2.61)] and remyocardial infarction [OR = 0.57, 95% CI = (0.25, 1.29)]. However, CR was associated with a marked reduction in the rate of revascularization [OR = 0.45, 95% CI = (0.27, 0.74)]. This analysis of current available data demonstrates that CR during primary PCI can put those patients with STEMI and MVD at risk. To clarify this issue, large RCTs are needed.
Keywords: Complete revascularization, Multivessel disease, ST‐elevation myocardial infarction
Introduction
Approximately 30–60% of patients with ST‐elevation myocardial infarction (STEMI) have multivessel coronary artery disease [[1], [2]]. The optimal treatment strategy for such patients at the primary procedure is controversial. Revascularization of the nonculprit artery at an early stage may increase the blood supply, and thus decrease the risk of revascularization (re‐VR) and remyocardial infarction (re‐MI), as well as improve cardiac function [3].
According to the guidelines of the American College of Cardiology/American Heart Association (ACC/AHA) [[4], [5]], patients with STEMI and multivessel disease (MVD) should be treated with culprit‐vessel‐only revascularization (COR), following which the nonculprit vessel can be addressed in an elective procedure. However, this recommendation is merely based on expert consensus (level of evidence: C), not on large‐sample randomized controlled trials (RCTs). As a result of improvements in stent technique and the use of new antiplatelet drugs (GP IIb/IIIa inhibitors), complete revascularization (CR) at an early stage attracts more and more attention.
Several studies have demonstrated inconsistent outcome for patients with CR at the primary stage [[6], [7], [8]]. To provide a quantitative analysis of short‐ and long‐term clinical outcomes, we performed a meta‐analysis of CR versus COR at the primary procedure in patients with STEMI.
Materials and methods
Search strategy
We searched Medline (PubMed database), Embase, and Cochrane databases for studies published between January 1966 and January 2011 using the terms “complete revascularization,” “ST‐elevated myocardial infarction,” and “multivessel disease.” We then searched the China National Knowledge Internet (CNKI, 1979–January 2011) and the Chinese Biomedical Literature Database (CBM, 1978–January 2011) in Chinese. Studies were identified manually, and cross‐references were also explored.
Definition and endpoints
In our meta‐analysis, we included RCTs and non‐RCTs that compared the two strategies in terms of prognosis in patients with STEMI and MVD in primary percutaneous coronary intervention (PCI). MVD was defined as the presence of ≥70% diameter stenosis (identified by angiography) in two or more coronary arteries. CR was defined as the procedure whereby the culprit and nonculprit vessels were opened simultaneously in the primary procedure. COR was defined as the procedure whereby the culprit vessel alone was opened in the primary procedure. Exclusion criteria were as follows: (1) study population included patients with rescue PCI; (2) patients undergoing CR not in a separate group; and (3) no control group (COR). Primary endpoints were short‐ and long‐term mortality. Secondary endpoints included rates of re‐MI, re‐VR, major adverse cardiac events (MACE), and renal dysfunction post intervention. As there is no unanimous definition of MACE, we used the definition of the individual research paper.
Quality assessment
According to the “Cochrane Handbook for Systematic Reviews of Interventions version 5.1.0,” quality assessment of RCTs includes random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, and selective reporting. Quality assessment of non‐RCTs (“Bracken MB” criterion, 1989) [9] includes four criteria: how allocation occurred, any attempt to balance groups by design, identification of prognostic factors, and case‐mix adjustment.
Statistics
Continuous variables are reported as the mean value ± standard deviation, and categorical variables are presented as risk ratios and 95% confidence intervals (CIs). Statistical analysis was performed using Review Manager 5.0. Heterogeneity was analyzed by means of standard Chi‐square tests, with p < 0.1 deemed statistically significant. The random effects model was used when heterogeneity was present, and sensitivity analysis was performed after excluding the studies with huge heterogeneity.
Results
Thirteen studies were included in the final analysis, four prospective studies including three RCTs [[3], [7], [10], [11]] and nine retrospective studies [[6], [8], [12], [13], [14], [15], [16], [17], [18]]. These 13 studies included three RCTs [[3], [7], [10]] and two important conference proceedings [[17], [18]]. Details of the screening process for studies are shown in Fig. 1. The quality assessment of studies is shown in Tables 1 and 2.
Figure 1.
Flow diagram of the reviewing process. CBM = Chinese Biomedical Literature Database; CCRT = Cochrane Controlled Trials Register; CNKI = China National Knowledge Internet; RCT = randomized controlled trial; STEMI = ST‐elevation myocardial infarction.
Table 1.
Quality assessment of eight non‐RCTs that compared complete revascularization versus culprit‐vessel‐only revascularization.
| First author of studies | How allocation occurred a | Any attempt to balance groups by design b | Identification of prognostic factors c | Case‐mix adjustment d |
|---|---|---|---|---|
| Corpus (2004) | Single‐center database, not mentioned | Not used | Reported complications | Not used |
| Khattab (2008) | Single‐center database, by date admission | Not used | Reported baseline characteristics | Not used |
| Varani (2008) | Single‐center database, by doctor | Not used | Reported age, gender, killip class, anterior myocardial infarction | Not used |
| Qarawani (2008) | Single‐center database, by doctor | Not used | Reported baseline characteristics | Not used |
| Cavender 2009 | Multicenter registry data, not mentioned | Not used | Reported baseline characteristics | Not used |
| Hannan 2010 | Multicenter registry data, not mentioned | Propensity score | Reported baseline characteristics | Not used |
| Toma 2010 | Single‐center database, not mentioned | Not used | Reported baseline characteristics | Not used |
| Dziewierz 2010 | Multicenter registry data, not mentioned | Not used | Not reported | Not used |
Non‐RCT = nonrandomized controlled trial.
Most data were acquired from single‐center database, and three trials reported the allocation method.
Only one non‐RCT used the propensity score match.
All the studies reported the baseline characteristics with the exception of the study of Dziewierz (2010).
Case‐mix adjustment methods were not used in any trial.
Table 2.
Quality assessment of three randomized controlled trials that compared complete revascularization versus culprit‐vessel‐only revascularization.
| First author of studies | Random sequence generation | Allocation concealment | Blinding of participants and personnel | Blinding of outcome assessment | Incomplete outcome data | Selective reporting |
|---|---|---|---|---|---|---|
| Carlo (2004) | Mentioned | Not mentioned | Not mentioned | Not mentioned | Complete | Not mentioned |
| Not described | ||||||
| Ochala (2004) | Mentioned | Not mentioned | Not mentioned | Not mentioned | Complete | Not mentioned |
| Not described | ||||||
| Politi (2010) | Computerized random | Not mentioned | Not mentioned | Not mentioned | Complete | Not mentioned |
None of the three trials reported information regarding concealment, blinding method, or selective reporting.
Characteristics of eligible studies
In total, 60,238 patients were enrolled, 8240 in the CR group and 51,998 in the COR group. Details of the studies' characteristics are shown in Table 3. Compared with the COR group, patients in the CR group had a lower rate of hypertension and hyperlipidemia. Two studies reported the rate of cardiogenic shock, five studies excluded patients with cardiogenic shock, and six trials reported the use of GP IIb/IIIa inhibitors. There was a lower rate of usage of drug‐eluting and heparin‐coated stents in the study conducted by Di Mario et al. [10]. Table 4 lists the clinical outcomes of the trials. Eleven studies reported short‐time outcomes (in hospital or at 30 days) and 10 studies reported long‐term outcomes, with a follow‐up time of between 0.25 and 2.5 years.
Table 3.
Patient numbers and baseline characteristics of included studies that compared CR versus COR.
| First author of studies | Number of patients (CR/COR) (n) | Mean age ± SD (CR/COR) (y) | Male (CR/COR) (%) | Diabetes (CR/COR) (%) | Hyperlipidemia (CR/COR) (%) | Hypertension (CR/COR) (%) | Smoker (CR/COR) (%) | Shock (CR/COR) (%) | IIb/IIIa inhibitors (CR/COR) (%) | Drug stent (CR/COR) （%） |
|---|---|---|---|---|---|---|---|---|---|---|
| Corpus (2004) a | 26/354 | NA | NA | NA | NA | NA | NA | NA | NA | NA |
| Carlo (2004) | 51/17 | 63.5 ± 12.4/ | 88.2/84.6 | 11.5/41.2 | 41.2/52.9 | 36.5/58.8 | 66.6/81.0 | Excluded | 75/82.4 | Heparin coated |
| 65.3 ± 7.4 | ||||||||||
| Ochala (2004) | 48/44 | 65 ± 8.3/ | 72.9/75.0 | 31.2/34.1 | 81.2/90.9 | 52.1/47.7 | 37.5/43.1 | Excluded | 51.5/50.7 | NA |
| 67 ± 7.9 | ||||||||||
| Khattab (2008) | 28/45 | 69 ± 12/ | 75/78 | 7/16 | 79/80 | 75/82 | 36/40 | 3.6/4.4 | 36/44 | 0 |
| 65 ± 13 | ||||||||||
| Varani (2008) a | 147/156 | 68.7 ± 13/ | 67/75 | NA | NA | NA | NA | NA | NA | NA |
| 69.8 ± 13 | ||||||||||
| Qarawani (2008) | 95/25 | 66 ± 3.2/ | 65/61 | 12.5/16 | 13.6/16 | 37.8/40 | 61/60 | Excluded | 94.7/96 | NA |
| 67 ± 3.7 | ||||||||||
| Cavender (2009) | 3134/25802 | 60(52‐72)/ | 71.5/72.1 | 24.7/23.4 | 56.5/58.6 | 60.4/63.2 | 63.2/64.8 | 13.8/10.3 | NA | NA |
| 62(53‐73) b | ||||||||||
| Politi (2010) | 65/84 | 64.5 ± 11.7 | 76.9/76.2 | 13.8/23.8 | NA | 49.2/59.5 | NA | Excluded | 100/100 | 7.7/11.9 |
| 66.5 ± 13.2 | ||||||||||
| Hannan (2010) | 503/503 | NA | 75.0/78.7 | 23.7/21.4 | NA | NA | NA | Excluded | NA | 56.7/61.1 |
| Toma (2010) | 217/1984 | 64(53,74)/ 64(55,73) b | 77.4/79.4 | 11.5/20 | NA | 47.5/55.6 | 38.2/39.9 | NA | 78.8/71.9 | 50.7/36.6 |
| Dziewierz (2010) a | 70/707 | NA | NA | NA | NA | NA | NA | NA | NA | NA |
| Rahman (2010) c | 578/1449 | NA | NA | NA | NA | NA | NA | NA | NA | NA |
| Kugelmass (2010) c | 3278/20828 | NA | 62.8/59.4 | NA | NA | NA | NA | NA | NA | NA |
COR = culprit‐vessel‐only revascularization; CR = complete revascularization; IIb/IIIa = glycoprotein IIb/IIIa inhibitors; NA = not available.
Baseline characteristics were not described in the three trials.
Ages in the two studies were reported as the median with 25th and 75th percentiles.
Baseline characteristics were not available from the conference proceedings.
Table 4.
Short‐ and long‐term clinical outcomes in the included studies that compared CR versus COR.
| First author of studies | Short term a | Long term b | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Follow‐up (d) | Mortality (CR/COR) (%) | Renal dysfunction (CR/COR) (%) | MACE(CR/COR) (%) | Follow‐up (y) | Mortality (CR/COR) (%) | MI (CR/COR) (%) | RVR (CR/COR) (%) | MACE (CR/COR) (%) | |
| Corpus (2004) | 30 | 19/6.9 | NA | 23/14.7 | 1 | 19/12 | 19/12 | NA | 35/28 |
| Carlo (2004) | In hospital | 1.9/0 | NA | 3.8/0 | 1 | 0/0 | 1.9/5.9 | 15.4/35.3 | 15.4/35.3 |
| Ochala (2004) c | NA | NA | NA | NA | 0.5 | 0/0 | 6.3/9.1 | 22.9/25 | 20.8/25 |
| Khattab (2008) | 30 | 3.6/4.5 | NA | 10.7/9.1 | 1 | 8/7 | 8/12 | 24/28 | 24/28 |
| Varani (2008) d | In hospital | 8.2/3.6 | NA | NA | NA | NA | NA | NA | NA |
| Qarawani 2008 | In hospital | 4.2/4 | 8.4/4 | NA | 1 | 9.4/8 | NA | NA | NA |
| Cavender (2009) d | In hospital | 7.85/5.12 | 2.31/1.81 | NA | NA | NA | NA | NA | NA |
| Politi (2010) | In hospital | 3.1/8.3 | 1.5/3.6 | NA | 2.5 | 9.2/15.5 | 3.1/8.3 | 9.2/33.3 | 23.1/50.0 |
| Hannan (2010) | In hospital | 3.4/2.0 | NA | NA | 1 | 7.1/5.5 | NA | NA | NA |
| Toma (2010) c | NA | NA | NA | NA | 0.25 | 12.5/5.6 | NA | NA | NA |
| Dziewierz (2010) | 30 | 12.9/5.9 | NA | 12.9/9.2 | 1 | 15.7/8.1 | NA | NA | NA |
| Rahman (2010) | In hospital | 5.0/4.4 | 18.9/18.5 | NA | 1 | 8.9/8.4 | NA | NA | NA |
| Kugelmass (2010) d | In hospital | 7.5/6.18 | 8.8/6.8 | NA | NA | NA | NA | NA | NA |
COR = culprit‐vessel‐only revascularization; CR = complete revascularization; MACE = major adverse cardiac events; MI = myocardial infarction; NA = not available; re‐VR = revascularization.
Results of mortality, renal dysfunction incidence, and MACE incidence of studies that compared CR versus COR during hospitalization or after 30‐day follow‐up.
Results of mortality, MI, re‐VR, and MACE of studies comparing CR versus COR over a long‐term follow‐up.
Data on short‐term outcomes were not available from these two trials.
Data on long‐term outcomes were not available from these three trials.
Short‐term mortality
Across the entire 11 studies, 57,945 patients were enrolled, 49,970 in the COR group and 7975 in the CR group. No heterogeneity was found among these trials (p = 0.14, I 2 = 32%); a fixed effects model was used. Compared with COR, CR was associated with an increased in‐hospital or 30‐day mortality [odds ratio (OR) = 1.39, 95% CI = (1.26, 1.53)] (Fig. 2). A similar result was found after excluding the conference proceedings [OR = 1.59, 95% CI = (1.39, 1.81)].
Figure 2.
Overall and stratified odds ratio for short‐term mortality in patients treated with CR versus COR. Size of squares corresponds to the weight of each study in the meta‐analysis; lozenges indicate summary effect estimate. The vertical line indicates an odds ratio of 1.0, equivalent to no difference between treatment groups. The diamond indicates that CR increased the short‐term mortality. CI = confidence interval; COR = culprit‐vessel‐only revascularization; CR = complete revascularization; RCT = randomized controlled trial.
Long‐term mortality
A total of 10 studies were evaluated, 5212 patients in the COR group where 378 patients died and 1681 patients in the CR group with 147 deaths. Heterogeneity was found (p = 0.07, I 2 = 47%); a randomized model was used. Patients treated with CR revealed a higher mortality rate in comparison with those treated with COR (CR vs. COR: 8.7% vs. 7.3%), and a significant difference was found between the two strategies [OR (95% CI) = 1.42 (1.01, 2.00), p = 0.04] (Fig. 3). A similar result was obtained following the exclusion of conference abstracts [OR (95% CI) = 1.60 (1.21, 2.11), p = 0.18, I² = 32%].
Figure 3.
Overall and stratified odds ratio for long‐term mortality in patients treated with CR versus COR. The diamond indicates that CR increased the long‐term mortality. CI = confidence interval; COR = culprit‐vessel‐only revascularization; CR = complete revascularization; RCT = randomized controlled trial.
Remyocardial infarction and revascularization
Fig. 4 demonstrates a comparison of the occurrence of re‐MI between the groups. Five articles reported on long‐term MI, 218 cases in the CR group and 544 cases in the COR group. No heterogeneity was found between the trials (p = 0.87, I 2 = 0%), and therefore a fixed effects model was used. The result showed that there was no significant difference between the two groups [OR = 0.57, 95% CI = (0.25, 1.29)]. Four trials reported the rate of re‐VR; no heterogeneity was found (p = 0.13, I 2 = 47%), and a fixed effects model was used. The analysis of outcomes showed that CR can reduce the rate of re‐VR markedly [CR vs. COR: 16.1% vs. 30%, OR = 0.45, 95% CI = (0.27, 0.74), p = 0.002].
Figure 4.
Overall and stratified odds ratio for long‐term myocardial infarction in patients treated with CR versus COR. Lozenges on the vertical line indicate no significant difference between the two groups. CI = confidence interval; COR = culprit‐vessel‐only revascularization; CR = complete revascularization; RCT = randomized controlled trial.
Renal dysfunction
Five studies reported on the rate of postoperative renal failure. The CR group enrolled 7150 patients, of whom 473 had transient renal failure (6.6%). The COR group enrolled 48,188 patients, and renal failure occurred in 2155 patients (4.5%). No heterogeneity was found (p = 0.21, I 2 = 32%), and a fixed effects model was used. The CR group had higher rates of renal failure (6.6% vs. 4.5%), which indicates that CR may increase the risk of renal failure after PCI in STEMI patients with MVD [OR (95% CI) = 1.23 (1.11, 1.37)] (Fig. 5). There was no statistical difference after excluding data from conference proceedings [OR = 1.27, 95% CI = (0.99, 1.62)].
Figure 5.
Analysis for the incidence of renal failure after treatment with CR or COR. Lozenge on the right side of vertical line indicates that culprit‐only revascularization may increase the risk of renal failure. CI = confidence interval; COR = culprit‐vessel‐only revascularization; CR = complete revascularization.
Short‐ and long‐term MACE
Four articles were identified that referred to short‐term MACE, 175 in the CR group and 1123 in the COR group. No heterogeneity was found (p = 0.98, I 2 = 0%), and a fixed effects model was used. The rates of short‐term MACE were 11.4% in the CR group and 10.8% in the COR group. However, there was no statistical difference between the groups [OR (95% CI) = 1.52 (0.88, 2.61)]. Five studies, a total of 762 patients, had data on long‐term MACE. Heterogeneity was found (p = 0.08, I 2 = 52%), and a randomized model was used. The result indicates that CR did not reduce the rate of long‐term MACE [OR = 0.6, 95% CI = (0.32, 1.11)]. Therefore, CR was not shown to reduce the rate of short‐ or long‐term MACE.
Short‐ and long‐term mortality excluding cardiogenic shock
Excluding patients with shock, six studies were included in the meta‐analysis. In short‐term mortality analysis, five studies [[6], [7], [8], [10], [14]] were included, 3415 patients in the CR group and 23,775 in the COR group. No heterogeneity was found (p = 0.54, I 2 = 0%), and a fixed effects model was used. The mortality rates were 3.3% in the CR group and 2.5% in the COR group. Compared with the COR group, the CR group was associated with an increased short‐term mortality rate [OR (95% CI) = 1.28 (1.03, 1.59)]. In long‐term mortality analysis, five articles [[3], [6], [7], [10], [14]] were included, 762 patients in the CR group and 673 in the COR group. No heterogeneity was found (p = 0.34, I 2 = 0%), and a fixed effects model was used. The mortality rates were 6.7% in the CR group and 6.4% in the COR group. There were no significant differences between the groups in terms of long‐term mortality [OR = 1.1, 95% CI = (0.72, 1.70)].
There was no apparent publication bias among the trials in terms of short‐term mortality (Supplementary Figs. 1–4). In addition, there was no apparent bias associated with other outcome parameters.
Discussion
The results of our analysis revealed an association between CR and increased short‐term mortality [OR = 1.39, 95% CI = (1.26, 1.53)], increased long‐term mortality [OR = 1.50, 95% CI = (1.02, 2.18)], and increased risk of renal failure [OR (95% CI) = 1.24 (1.11, 1.38)] in patients with STEMI and MVD, at the primary procedure. In addition, CR did not appear to reduce the rate of short‐term MACE and re‐MI; however, it can reduce the rate of re‐VR markedly.
MVD is an important predictor of long‐term outcome in STEMI patients. Patients with MVD have a lower ejection fraction, a higher rate of re‐MI and re‐VR, and a worse prognosis [19]. Theoretically, CR can maximally restore myocardial blood supply, improve cardiac function, decrease the rate of re‐VR, and reduce medical costs. On the other hand, CR may increase the risk of operation, amount of contrast, and risk of renal failure. Much controversy surrounds the two strategies. The ACC/AHA does not suggest re‐VR except for the culprit vessel. The results of this meta‐analysis support the current guidelines for the management of patients with STEMI, which indicate that the culprit vessel alone should be treated and that the nonculprit vessel can be addressed in an elective procedure.
Politi et al. [7] enrolled 214 patients, who did not have cardiogenic shock, and divided them into three groups: CR, COR, and staged revascularization (SR). A higher rate of hospital death was observed in the COR group: 8.3% in COR group, 3.1% in CR group, and 0% in SR group (p = 0.037). After a follow‐up of 2.5 years, the COR group had a higher rate of MACE, re‐VR, and rehospitalization (p < 0.001). However, there was no significant difference in re‐MI (p = 0.412) and long‐term mortality (COR vs. CR vs. SR: 15.5% vs. 9.2% vs. 6.2%, p = 0.17). The study of Ochala et al. [3] also excluded those with cardiac shock. Compare with SR (two‐staged PCI), CR (one‐staged PCI) decreased the rate of re‐MI (6.3% vs. 9.1%), re‐VR (9.2% vs. 33.3%), and MACE (20.8% vs. 25%). However, there were no deaths.
Only two studies [[8], [11]] reported the rate of cardiogenic shock in this meta‐analysis. Five trials excluded those with cardiogenic shock. The proportion of cardiogenic shock was 5.3% in the CR group and 5.1% in the COR group. As a result of these low percentages, conclusions of this meta‐analysis are not applicable generally to patients with cardiogenic shock. In the analysis of those without cardiogenic shock, the results showed that CR could increase short‐term mortality, but might not affect long‐term mortality. However, it is important to note that only three small‐sample‐size trials had death events in terms of long‐term mortality. The test efficiency may be too low to discover real differences between the groups.
A large contrast volume has a deleterious effect on renal function and prognosis in patients with STEMI. According to the Marenzi et al. [20], larger contrast volume (>300 mL) is associated with a higher rate of contrast‐induced nephropathy, [OR = 2.80, 95% CI = (1.17，6.68), p = 0.02]. Moreover, patients who developed nephropathy had significantly higher in‐hospital mortality rates (31% vs. 0.6%, p = 0.001). In our analysis, the CR group had a greater contrast volume compared with the COR group in four trials [[3], [7], [8], [11]]. Cavender et al. [8] found that the mean volume of contrast was 255 mL in the CR group and 200 mL in the COR group (p < 0.01), while higher rates of renal failure were observed in patients with CR (CR vs. COR: 2.31% vs. 1.81%, p = 0.09).
Sethi et al. [21], who compared the two strategies, found that there was no significant difference in short‐ and long‐term mortality, MACE, and re‐PCI. The authors defined CR as “during primary procedure or index hospitalization,” and thus their included studies were different from ours. In addition, patients who received staged PCI may have a better outcome compared with the CR or the COR group [7]. As a result, the CR group, which included staged PCI, may have a better prognosis.
The meta‐analysis by Navarese et al. [22] showed similar outcomes between the groups, apart from a decreased re‐PCI rate in the CR group. The meta‐analysis included only 10 articles, and two studies [[23], [24]] did not match our inclusion criteria. In addition, we included two large sample trials [[6], [7]]. Of note is the higher short‐ and long‐term mortality observed in the CR group in the study of Navarese et al., although no statistical significant difference was found.
Study limitations
Our meta‐analysis included 13 studies, three of which were RCTs, and all of which were small‐sample trials. Only one non‐RCT used the propensity score match [6]. Overall, comparability between groups was low, and many potential confounding factors might exist. This might affect the strength of evidence presented by this meta‐analysis. In addition, the follow‐up time was limited, with two RCTs following patients for 0.5 year [3] and 1 year [10], respectively, and there were no deaths in the two RCTs. To date, the exact long‐term clinical outcomes have not been clear from the available data. Toma et al. [15] reported only on the 3‐month outcome. In addition, in order to make the data collection as complete as possible, we included two important conference proceedings with incomplete data. However, a similar statistical result was obtained after they were excluded, with the exception of the result for renal dysfunction. Moreover, in our meta‐analysis, the COR group included staged PCI, but the definition was not consistent in some trials. Politi et al. [7] separated staged PCI into a distinct group. As a result, the differences between the two groups might have been exaggerated in our analysis.
In summary, our analysis shows that CR as a strategy in primary PCI for patients with STEMI and MVD potentially increases the risk of short‐ and long‐term mortality, even though there is a reduction in the re‐VR rate. Therefore, COR may be the treatment of choice according to currently available evidence.
Supplementary data
Supplementary Figure 1 Overall and stratified odds ratio for re‐VR in patients treated with CR versus COR. CI = confidence interval; COR = culprit‐vessel‐only revascularization; CR = complete revascularization; RCT = randomized controlled trial; re‐VR = revascularization.
Supplementary Figure 2 Overall odds ratio for short‐term MACE in patients treated with CR versus COR. CI = confidence interval; COR = culprit‐vessel‐only revascularization; CR = complete revascularization; MACE = major adverse cardiac events.
Supplementary Figure 3 Overall and stratified odds ratio for long‐term MACE in patients treated with CR versus COR. CI = confidence interval; COR = culprit‐vessel‐only revascularization; CR = complete revascularization; MACE = major adverse cardiac events; RCT = randomized controlled trial.
Supplementary Figure 4 Funnel plot for included studies that reported short‐term mortality.
Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/j.kjms.2012.08.024
References
- [1]. Muller D.W., Topol E.J., Ellis S.G., Sigmon K.N., Lee K., Califf R.M.. Multivessel coronary artery disease: a key predictor of short‐term prognosis after reperfusion therapy for acute myocardial infarction. Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) Study Group. Am Heart J. 1991; 121: 1042–1049. [DOI] [PubMed] [Google Scholar]
- [2]. Jaski B.E., Cohen J.D., Trausch J., Marsh D.G., Bail G.R., Overlie P.A., et al. Outcome of urgent percutaneous transluminal coronary angioplasty in acute myocardial infarction: comparison of single‐vessel versus multivessel coronary artery disease. Am Heart J. 1992; 124: 1427–1433. [DOI] [PubMed] [Google Scholar]
- [3]. Ochala A., Smolka G.A., Wojakowski W., Dudek D., Dziewierz A., Krolikowski Z., et al. The function of the left ventricle after complete multivessel one‐stage percutaneous coronary intervention in patients with acute myocardial infarction. J Invasive Cardiol. 2004; 16: 699–702. [PubMed] [Google Scholar]
- [4]. Antman E.M., Anbe D.T., Armstrong P.W., Bates E.R., Green L.A., Hand M., et al. ACC/AHA guidelines for the management of patients with ST‐elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). J Am Coll Cardiol. 2004; 44. [DOI] [PubMed] [Google Scholar]
- [5]. Antman E.M., Hand M., Armstrong P.W., Bates E.R., Green L.A., Halasyamani L.K., et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST‐elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2008; 51: 210–247. [DOI] [PubMed] [Google Scholar]
- [6]. Hannan E.L., Samadashvili Z., Walford G., Holmes D.R. Jr., Jacobs A.K., Stamato N.J., et al. Culprit vessel percutaneous coronary intervention versus multivessel and staged percutaneous coronary intervention for ST‐segment elevation myocardial infarction patients with multivessel disease. JACC Cardiovasc Interv. 2010; 3: 22–31. [DOI] [PubMed] [Google Scholar]
- [7]. Politi L., Sgura F., Rossi R., Monopoli D., Guerri E., Leuzzi C., et al. A randomised trial of target‐vessel versus multi‐vessel revascularisation in ST‐elevation myocardial infarction: major adverse cardiac events during long‐term follow‐up. Heart. 2010; 96: 662–667. [DOI] [PubMed] [Google Scholar]
- [8]. Cavender M.A., Milford‐Beland S., Roe M.T., Peterson E.D., Weintraub W.S., Rao S.V.. Prevalence, predictors, and in‐hospital outcomes of non‐infarct artery intervention during primary percutaneous coronary intervention for ST‐segment elevation myocardial infarction (from the National Cardiovascular Data Registry). Am J Cardiol. 2009; 104: 507–513. [DOI] [PubMed] [Google Scholar]
- [9]. Deeks J.J., Dinnes J., D'Amico R., Sowden A.J., Sakarovitch C., Song F., et al. Evaluating non‐randomised intervention studies. Health Technol Assess. 2003; 7: 1–173. [DOI] [PubMed] [Google Scholar]
- [10]. Di Mario C., Mara S., Flavio A., Imad S., Antonio M., Anna P., et al. Single vs multivessel treatment during primary angioplasty: results of the multicentre randomised HEpacoat for cuLPrit or multivessel stenting for Acute Myocardial Infarction (HELP AMI) Study. Int J Cardiovasc Intervent. 2004; 6: 128–133. [DOI] [PubMed] [Google Scholar]
- [11]. Khattab A.A., Abdel‐Wahab M., Röther C., Liska B., Toelg R., Kassner G., et al. Multi‐vessel stenting during primary percutaneous coronary intervention for acute myocardial infarction. A single‐center experience. Clin Res Cardiol. 2008; 97: 32–38. [DOI] [PubMed] [Google Scholar]
- [12]. Corpus R.A., House J.A., Marso S.P., Grantham J.A., Huber K.C. Jr., Laster S.B., et al. Multivessel percutaneous coronary intervention in patients with multivessel disease and acute myocardial infarction. Am Heart J. 2004; 148: 493–500. [DOI] [PubMed] [Google Scholar]
- [13]. Varani E., Balducelli M., Aquilina M., Vecchi G., Hussien M.N., Frassineti V., et al. Single or multivessel percutaneous coronary intervention in ST‐elevation myocardial infarction patients. Catheter Cardiovasc Interv. 2008; 72: 927–933. [DOI] [PubMed] [Google Scholar]
- [14]. Qarawani D., Nahir M., Abboud M., Hazanov Y., Hasin Y.. Culprit only versus complete coronary revascularization during primary PCI. Int J Cardiol. 2008; 123: 288–292. [DOI] [PubMed] [Google Scholar]
- [15]. Toma M., Buller C.E., Westerhout C.M., Fu Y., O'Neill W.W., Holmes D.R. Jr., et al. Non‐culprit coronary artery percutaneous coronary intervention during acute ST‐segment elevation myocardial infarction: insights from the APEX‐AMI trial. Eur Heart J. 2010; 31: 1701–1707. [DOI] [PubMed] [Google Scholar]
- [16]. Dziewierz A., Siudak Z., Rakowski T., Zasada W., Dubiel J.S., Dudek D.. Impact of multivessel coronary artery disease and noninfarct‐related artery revascularization on outcome of patients with ST‐elevation myocardial infarction transferred for primary percutaneous coronary intervention (from the EUROTRANSFER Registry). Am J Radiol. 2010; 106: 342–347. [DOI] [PubMed] [Google Scholar]
- [17]. Rahman M., Nfor T., Allaqaband S., Gupta A., Bajwa T., Svcs A.C., et al. Clinical and angiographic outcomes in patients with ST‐segment elevation myocardial infarction undergoing single versus multiple vessel percutaneous coronary intervention. J Am Coll Cardiol. 2010; 55. [Google Scholar]
- [18]. Kugelmass A.D., Brown P.P., Reynolds M.R., Culler S.D., Simon A.W., Cohen D.J., et al. Is multi‐vessel primary PCI advisable? Differences in clinical outcomes among Medicare beneficiaries undergoing single versus multi‐vessel PCI during a primary ST segment elevation myocardial infarction hospitalization in fiscal year 2007. J Am Coll Cardiol. 2010; 55. [Google Scholar]
- [19]. Parodi G., Memisha G., Valenti R., Trapani M., Migliorini A., Santoro G.M., et al. Five year outcome after primary coronary intervention for acute ST elevation myocardial infarction: results from a single centre experience. Heart. 2005; 91: 1541–1544. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [20]. Marenzi G., Lauri G., Assanelli E., Campodonico J., De Metrio M., Marana I., et al. Contrast‐induced nephropathy in patients undergoing primary angioplasty for acute myocardial infarction. J Am Coll Cardiol. 2004; 44: 1780–1785. [DOI] [PubMed] [Google Scholar]
- [21]. Sethi A., Bahekar A., Bhuriya R., Singh S., Ahmed A., Khosla S.. Complete versus culprit only revascularization in acute ST elevation myocardial infarction: a meta‐analysis. Catheter Cardiovasc Interv. 2011; 77: 163–170. [DOI] [PubMed] [Google Scholar]
- [22]. Navarese E.P., De Servi S., Buffon A., Suryapranata H., De Luca G.. Clinical impact of simultaneous complete revascularization vs. culprit only primary angioplasty in patients with ST‐elevation myocardial infarction and multivessel disease: a meta‐analysis. J Thromb Thrombolysis. 2011; 31: 217–225. [DOI] [PubMed] [Google Scholar]
- [23]. Roe M.T., Cura F.A., Joski P.S., Garcia E., Guetta V., Kereiakes D.J., et al. Initial experience with multivessel percutaneous coronary intervention during mechanical reperfusion for acute myocardial infarction. Am J Cardiol. 2001; 88: 170–173. [DOI] [PubMed] [Google Scholar]
- [24]. Mohamad T., Bernal J.M., Kondur A., Hari P., Nelson K., Niraj A., et al. Coronary revascularization strategy for ST elevation myocardial infarction with multivessel disease: experience and results at 1‐year follow‐up. Am J Ther. 2011; 18: 92–100. [DOI] [PubMed] [Google Scholar]