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Systematic Review/Meta-analysis| Volume 34, ISSUE 12, P1573-1580, December 2018

Deferred vs Immediate Stenting in Primary Percutaneous Coronary Intervention: A Collaborative Meta-analysis of Randomized Trials With Cardiac Magnetic Resonance Imaging Data

Published:August 06, 2018DOI:https://doi.org/10.1016/j.cjca.2018.07.480
Deferred vs Immediate Stenting in Primary Percutaneous Coronary Intervention: A Collaborative Meta-analysis of Randomized Trials With Cardiac Magnetic Resonance Imaging Data
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      Abstract

      Background

      The role of deferred vs immediate stenting during primary percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) remains controversial.

      Methods

      We undertook a collaborative meta-analysis of study-level data by searching electronic scientific databases for investigations of primary PCI patients randomized to deferred or immediate stenting and subsequent cardiac magnetic resonance imaging. Primary angiographic and imaging outcomes were slow/no-reflow and microvascular obstruction (MVO), respectively. Main secondary outcome was recurrent ischemia.

      Results

      Among 4 trials, a total of 1570 patients with STEMI were assigned to primary PCI with either deferred (n = 779) or immediate stenting (n = 791). Of these, 797 participants had analyzable cardiac magnetic resonance imaging examinations. Median clinical follow-up was 9 months. Patients treated with deferred stenting showed a lower risk of developing slow/no-reflow in the culprit vessel (risk ratio [RR], 0.54 [95% confidence interval (CI), 0.41-0.72]; P < 0.001), a similar risk for MVO (RR, 0.93 [95% CI, 0.76-1.14]; P = 0.51), and trended higher in the risk of recurrent ischemia (RR, 2.42 [95% CI, 0.88-6.63]; P = 0.09) compared with those treated with immediate stenting. The treatment effect for slow/no-reflow and MVO correlated with a thrombus score grade > 3 at the baseline angiography and with the total stent length implanted in the culprit artery.

      Conclusions

      A strategy of deferred stenting during primary PCI improves angiographic but not imaging or clinical outcomes compared with immediate stenting. The potential lower risk for myocardial injury by deferred stenting in primary PCI patients with STEMI and high thrombus burden requires a confirmation in adequately sized randomized trials.

      Résumé

      Contexte

      L’effet de l’implantation immédiate, comparativement à une implantation différée, d’une endoprothèse durant une intervention coronarienne percutanée (ICP) primaire chez des patients présentant un infarctus du myocarde (IM) avec sus-décalage du segment ST demeure un sujet de controverse.

      Méthodologie

      Nous avons réalisé une méta-analyse collaborative des données obtenues dans le cadre d’études en cherchant, dans les bases de données scientifiques électroniques, celles qui portaient sur des patients ayant subi une ICP primaire et ayant été répartis au hasard pour l’implantation immédiate ou différée d’une endoprothèse vasculaire suivie d’un examen par résonance magnétique cardiaque. Les paramètres d’évaluation principaux de l’angiographie et de l’imagerie étaient le débit lent (slow flow) ou la non-reperfusion (no-reflow) et l’obstruction microvasculaire (OMV), respectivement. Le paramètre d’évaluation secondaire était l’ischémie récurrente.

      Résultats

      Au total, dans les 4 essais, 1570 patients ayant un IM avec sus-décalage du segment ST ont subi une ICP primaire prévoyant l’implantation d’une endoprothèse vasculaire différée (n = 779) ou immédiate (n = 791). De ce nombre, 797 participants avaient passé des examens d’imagerie par résonance magnétique cardiaque dont les résultats étaient analysables. Le suivi clinique médian était de 9 mois. Les patients traités par une implantation différée présentaient un risque moins élevé de débit lent ou de non-reperfusion dans l’artère en cause (risque relatif [RR] de 0,54 [intervalle de confiance (IC) à 95 % de 0,41 à 0,72]; p < 0,001), un risque similaire d’OMV (RR de 0,93 [IC à 95 % de 0,76 à 1,14]; p = 0,51) et une tendance à un risque plus élevé d’ischémie récurrente (RR de 2,42 [IC à 95 % de 0,88 à 6,63]; p = 0,09) que ceux qui avaient fait l’objet d’une implantation immédiate. L’effet thérapeutique relativement au débit lent/à la non-reperfusion et à l’OMV était corrélé à un thrombus de grade supérieur à 3 à l’angiographie initiale, et à la longueur totale de l’endoprothèse implantée dans l’artère en cause.

      Conclusions

      La stratégie d’implantation différée de l’endoprothèse durant une ICP primaire améliore les paramètres d’évaluation angiographiques, mais pas les résultats cliniques ou ceux observés à l’imagerie comparativement à l’implantation immédiate. La possibilité d’une diminution du risque de lésion myocardique grâce à l’implantation différée de l’endoprothèse chez les patients ayant un IM avec sus-décalage du segment ST et une charge thrombotique importante qui subissent une ICP primaire nécessite une confirmation par des essais cliniques à répartition aléatoire de dimension appropriée.
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      Article info

      Publication history

      Published online: August 06, 2018
      Accepted: July 28, 2018
      Received: May 15, 2018

      Footnotes

      See editorial by Ben-Shoshan and Jolicoeur, pages 1541–1542 of this issue.

      See page 1579 for disclosure information.

      Identification

      DOI: https://doi.org/10.1016/j.cjca.2018.07.480

      Copyright

      © 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

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