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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Article info
Publication history
Published online: March 18, 2019
Accepted:
March 10,
2019
Received:
December 11,
2018
Footnotes
See page 1056 for disclosure information.
Identification
Copyright
© 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
