St. Michael's Hospital, Toronto, Canada.
Am Heart J. 2013 Oct;166(4):684-693.e1. doi: 10.1016/j.ahj.2013.07.027. Epub 2013 Sep 20.
In patients with ST-elevation myocardial infarction (STEMI) and multivessel disease, guidelines recommend infarct-related artery (IRA) only intervention during primary percutaneous coronary intervention (PCI) except in patients with hemodynamic instability. To assess the available evidence, we performed a systematic review and meta-analysis comparing outcomes of non-IRA PCI as an adjunct to primary PCI (same sitting PCI [SS-PCI]) with IRA only PCI (IRA-PCI) in the setting of STEMI.
A comprehensive search identified 14 studies [11 cohort, 3 randomized controlled trials] comprising of 35,239 patients. For cohort studies, patients undergoing SS-PCI had higher rate of anterior infarction (48% vs. 45%, P = .04) and cardiogenic shock (11% vs. 9%, P = .0001) at baseline compared with IRA-PCI. The primary composite end point of death, myocardial infarction and revascularization was higher in the SS-PCI group in the short term (OR, 1.63; CI, 1.12-2.37) and long term (OR, 1.60; CI, 1.18-2.16). However, after excluding patients with shock, there was no difference in primary endpoint for the short (OR, 1.33; CI, 0.67-2.63) and long term (OR, 1.39; CI, 0.80-2.42) follow-up. In analyses limited to randomized controlled trials, primary end point was similar during short term (OR, 0.79; CI, 0.19-3.28) and significantly lower for SS-PCI group in the long term (OR, 0.55; CI, 0.34-0.91).
There is paucity of randomized data to guide management of STEMI patients with multivessel disease. SS-PCI group in cohort studies has higher baseline risk compared to IRA-PCI. The primary end point is higher for SS-PCI in observational cohort studies but this difference did not persist after exclusion of shock patients and for analysis limited to randomized controlled trials. These findings underscore the need of a large randomized controlled trial to guide therapy for a commonly encountered clinical situation.
在 ST 段抬高型心肌梗死（STEMI）合并多支血管病变的患者中，指南建议在直接经皮冠状动脉介入治疗（PCI）期间仅对梗死相关动脉（IRA）进行干预，除非患者存在血流动力学不稳定的情况。为了评估现有证据，我们对比较 STEMI 患者中直接 PCI 时同时对非 IRA 进行介入治疗（同期 PCI[SS-PCI]）与仅对 IRA 进行介入治疗（IRA-PCI）的结局的研究进行了系统评价和荟萃分析。
全面检索确定了 14 项研究[11 项队列研究，3 项随机对照试验]，共纳入 35239 例患者。对于队列研究，与 IRA-PCI 相比，行 SS-PCI 的患者基线时前壁梗死（48%比 45%，P=.04）和心源性休克（11%比 9%，P=.0001）的发生率更高。短期（OR，1.63；95%CI，1.12-2.37）和长期（OR，1.60；95%CI，1.18-2.16），SS-PCI 组的主要复合终点（死亡、心肌梗死和血运重建）发生率更高。然而，在排除休克患者后，短期（OR，1.33；95%CI，0.67-2.63）和长期（OR，1.39；95%CI，0.80-2.42）随访时，主要终点没有差异。在仅纳入随机对照试验的分析中，短期（OR，0.79；95%CI，0.19-3.28）和长期（OR，0.55；95%CI，0.34-0.91）随访时，SS-PCI 组的主要终点相似。
目前缺乏随机数据来指导 STEMI 合并多支血管病变患者的治疗。与 IRA-PCI 相比，队列研究中的 SS-PCI 组基线风险更高。观察性队列研究中 SS-PCI 组的主要终点更高，但排除休克患者后，这种差异并不存在，且在仅纳入随机对照试验的分析中也不存在。这些发现强调了需要进行一项大型随机对照试验来指导这种常见临床情况的治疗。
