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Canadian Journal of Cardiology

Early Complete Revascularization in Hemodynamically Stable Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Disease

Published:March 18, 2019DOI:https://doi.org/10.1016/j.cjca.2019.03.006

      Abstract

      Background

      The optimal strategy and timing of revascularization in hemodynamically stable patients with ST-segment elevation myocardial infarction and multivessel disease is unknown. We performed a systematic review and meta-analysis to explore the comparative efficacy and safety of early complete revascularization vs culprit-only or staged revascularization in this setting.

      Methods

      We searched the literature for randomized clinical trials that assessed this issue. Early complete revascularization was defined as a complete revascularization achieved during the index procedure or within 72 hours. Efficacy outcomes were major adverse cardiovascular events, myocardial infarction, repeat revascularization, and all-cause mortality. Safety outcomes were all bleeding events, stroke, and contrast-induced acute kidney injury.

      Results

      Nine randomized clinical trials with a total of 2837 patients were included; 1254 received early complete revascularization and 1583 were treated with other revascularization strategies. After a mean follow-up of 15.3 ± 9.4 months early complete revascularization was associated with a lower risk of major adverse cardiovascular events (relative risk [RR], 0.51; 95% confidence interval [CI], 0.41-0.62; P < 0.00001; number needed to treat = 8), myocardial infarction (RR, 0.59; 95% CI, 0.40-0.87), and repeat revascularization (RR, 0.39; 95% CI, 0.28-0.55) without any difference in all-cause mortality and in safety outcomes compared with culprit-only or staged revascularization. Moreover, fractional flow reserve-guided complete revascularization reduced the incidence of repeat revascularization compared with angiography-guided procedure (χ2 = 4.36; P = 0.04).

      Conclusions

      Early complete revascularization should be considered in hemodynamically stable patients with ST-segment elevation myocardial infarction and multivessel disease deemed suitable for percutaneous interventions. Fractional flow reserve-guided complete revascularization might be superior to angiography-guided procedures in reducing need for further interventions.

      Résumé

      Contexte

      On ignore quelle est la stratégie optimale et le moment le plus approprié pour la revascularisation chez les patients stables sur le plan hémodynamique qui ont subi un infarctus du myocarde avec élévation du segment ST et présentent une atteinte polyvasculaire. Nous avons effectué une revue systématique et une méta-analyse en vue de comparer l'efficacité et l'innocuité d'une revascularisation complète précoce et d'une revascularisation de la seule artère en cause ou par étapes chez les patients présentant ces caractéristiques.

      Méthodologie

      Nous avons effectué une recension de la littérature traitant des essais cliniques à répartition aléatoire pertinents. Une revascularisation complète précoce a été définie comme étant une revascularisation effectuée au cours de l’intervention initiale ou dans les 72 heures de celle-ci. Les paramètres d'évaluation de l'efficacité étaient les événements cardiovasculaires indésirables majeurs, l'infarctus du myocarde, la revascularisation répétée et la mortalité toutes causes confondues. Les paramètres d'évaluation de l'innocuité étaient les événements hémorragiques totaux, les accidents vasculaires cérébraux et l'insuffisance rénale aiguë induite par les produits de contraste.

      Résultats

      Neuf essais cliniques à répartition aléatoire menés auprès de 2837 patients au total ont été inclus; 1254 patients avaient été traités par revascularisation complète précoce et 1583, par une autre stratégie de revascularisation. Après une période de suivi moyenne de 15,3 ± 9,4 mois, la revascularisation complète précoce était associée à un risque plus faible d'événement cardiovasculaire indésirable majeur (risque relatif [RR], 0,51; intervalle de confiance [IC] à 95 %, de 0,41 à 0,62; p < 0,00001; nombre de sujets à traiter = 8), d'infarctus du myocarde (RR, 0,59; IC à 95 %, de 0,40 à 0,87) et de revascularisation répétée (RR, 0,39; IC à 95 %, de 0,28 à 0,55) sans aucune différence sur le plan de la mortalité toutes causes confondues et des paramètres d'évaluation de l'innocuité comparativement à la revascularisation de la seule artère en cause ou à la revascularisation par étapes. De plus, la revascularisation complète guidée par la mesure de la réserve coronaire a entraîné une réduction de l'incidence des revascularisations répétées comparativement à l'intervention guidée par angiographie (χ2 = 4,36; p = 0,04).

      Conclusions

      La revascularisation complète précoce devrait être envisagée chez les patients stables sur le plan hémodynamique qui ont subi un infarctus du myocarde avec élévation du segment ST, qui présentent une atteinte polyvasculaire et chez lesquels une intervention percutanée est indiquée. La revascularisation complète guidée par la mesure de la réserve coronaire pourrait s’avérer supérieure aux techniques guidées par angiographie pour réduire la nécessité d'interventions futures.
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