Original title: Complete Versus Culprit-Only Revascularization for Patients with Multi-Vessel Disease Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction: A Systematic Review and Meta-analysis. Reference: Kevin R et al. American Heart Journal, article in press.
Primary angioplasty is the preferred reperfusion strategy in patients experiencing a STEMI as it has proven superior to fibrinolysis in reducing morbidity and mortality. Approximately 40 to 70 % of those receiving primary angioplasty have at least one additional severe injury culprit vessel and this subgroup of patients are twice year mortality than those with a single lesion. Besides the above, there is evidence that the instability of plaque is not merely limited to the culprit artery.
All current guidelines recommend multivessel angioplasty only in the context of hemodynamic instability but information has emerged, both observational and randomized studies that challenge this paradigm.
The aim of this systematic review and meta-analysis was to compare the safety and efficacy of complete revascularization versus treating only the culprit vessel in patients with multivessel disease undergoing primary angioplasty. A total of 26 studies were included in the analysis ( 3 randomized and 23 non-randomized ) with 46324 patients (7886 receiving multivessel angioplasty and 38438 only the culprit vessel). Multi-vessel angioplasty was performed during the index intervention in 16 studies, in stages but during the same hospitalization in 9 works, elective and after discharge in another 7. Overall there was no significant difference in-hospital mortality between the two strategies in both randomized and non- randomized studies. However, in-hospital mortality increased in those patients whom multiple vessel angioplasty was performed in the same procedure (OR 1.35 , 95 % CI 1.19 to 1.54 , P < 0.001). Unlike the above, those patients who received complete stage revascularization during hospitalization and not the same procedure, benefited in terms of survival (OR 0.35 , 95 % CI 0.21 to 0.59 , P < 0.001 ). The long-term mortality (mean 14.5 months) favored complete revascularization both randomized trials (OR 0.74, 95 % CI 0.65 to 0.85 , P < 0.001) and non- randomized (OR 0.75 , 95 % CI 0.65 to 0.86 p < 0.001).
Conclusion:
The multi-vessel angioplasty in stages after treating the culprit artery in the context of STEMI reduces mortality in the short and long term. Randomized studies are needed to confirm these findings .
Editorial comment:
There was significant heterogeneity between studies, especially when analyzing in-hospital mortality of patients who received complete revascularization during the index procedure and is also difficult to rule out that this has not been associated with patients admitted in cardiogenic shock (11 studies included them). Definitely the question remains clearly unanswered and further studies are needed, but it appears that the class III indication of complete revascularization of all guides is becoming obsolete.
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