Multivessel disease is often present in ST elevation acute myocardial infarction (STEMI) patients. The AHA/ACC 2021 revascularization guidelines recommend staged complete revascularization as class I, single-setting complete revascularization as class 2b, and recommend against culprit only revascularization.
At present, we have more randomized studies (BIOVASC, FIRE and MULTISTAR) comparing staged vs single-setting complete revascularization, but we lack information to decide on the best strategy.
This was a meta-analysis of 16 randomized studies including 11,876 STEMI and NSTEMI patients undergoing culprit only, single-setting, and staged complete revascularization, excluding those with cardiogenic shock.
Primary end point was cardiovascular death or AMI.
3,056 patients received single-setting complete revascularization (25.7%), 4,328 patients received staged complete revascularization (36.4%) and 4,492 patients received culprit-only revascularization (37.8%). Mean age was 65 and they were mostly men.
Primary end point resulted in favor of single-setting complete revascularization (odds ratio [OR], 0.52 [95% CI, 0.41–0.65]; OR, 0.74 [95% CI, 0.62–0.88] for staged complete and culprit only revascularization respectively), making this one the strategy of choice, followed by complete staged and finally culprit only.
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Reduction in adverse events rate (MACE) also favored single-setting complete revascularization over the other two (OR, 0.42 [95% CI, 0.32–0.56]; OR, 0.62 [95% CI, 0.47–0.82] for complete staged and culprit only respectively), also all-cause mortality and AMI (OR, 0.52 [95% CI, 0.40–0.67]; OR, 0.78 [95% CI, 0.67–0.91]), AMI (OR, 0.39 [95% CI, 0.26–0.57]; OR, 0.73 [95% CI, 0.59–0.90]) and need for unplanned revascularization (OR, 0.30 [95% CI, 0.18–0.47]; OR, 0.46 [95% CI, 0.30–0.71]).
There were no differences in cardiovascular mortality between the strategies.
These results were consistent across STEMI, NSTEMI and unstable angina patients.
Conclusion
Single-setting complete revascularization might offer greater reduction of cardiovascular events rate in patients with acute myocardial infarction and multivessel disease. We need more, large scale, randomized studies comparing single-setting vs staged complete revascularization procedures to better assess the optimal timing for complete revascularization.
Dr. Carlos Fava.
Member of the Editorial Board of SOLACI.org.
Reference: Muhammad Haisum Maqsood, et al. Circ Cardiovasc Interv. 2024;17:e013737. DOI: 10.1161/CIRCINTERVENTIONS.123.013737.
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