Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
Division of Cardiology, McMaster University, Hamilton, Ontario, Canada.
Am Heart J. 2014 Jan;167(1):1-14.e2. doi: 10.1016/j.ahj.2013.09.018. Epub 2013 Oct 16.
Patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease who undergo primary percutaneous coronary intervention (PCI) are most commonly treated with PCI to the culprit lesion only. Whether a strategy of complete revascularization in these patients is superior is unknown. We performed a meta-analysis comparing the benefits and risks of routine culprit-only PCI vs multivessel PCI in STEMI.
MEDLINE, EMBASE, ISI Web of Science, and The Cochrane Register of Controlled Trials were searched from 1996 to January 2011. Relevant conference abstracts were searched from January 2002 to January 2011. Studies included STEMI with multivessel disease receiving primary PCI. The primary end point was long-term mortality. Data were combined using a fixed-effects model.
Of 507 citations, 26 studies (3 randomized, 23 nonrandomized; 46,324 patients, 7886 multivessel PCI and 38,438 culprit-only PCI) were included. There was no significant difference in hospital mortality with multivessel PCI vs culprit-only PCI (odds ratio [OR] 1.11, 95% CI 0.98-1.25, P = .10 [randomized OR 0.24, 95% CI 0.06-0.91, P = .04; nonrandomized OR 1.12, 95% CI 1.00-1.27, P = .06]). However, if multivessel PCI during index catheterization was performed, hospital mortality was increased (OR 1.35, 95% CI 1.19-1.54, P < .001). When multivessel PCI was performed as a staged procedure, hospital mortality was lower (OR 0.35, 95% CI 0.21-0.59; P < .001; P interaction < .001). Reduced long-term mortality (OR 0.74, 95% CI 0.65-0.85, P < .001[randomized OR 0.61, 95% CI 0.28-1.33, P = .22; nonrandomized OR 0.75, 95% CI 0.65-0.86, P < .001]) and repeat PCI (OR 0.65; 95% 0.46-0.90, P = .01[randomized OR 0.31, 95% CI 0.17-0.57, P < .001; nonrandomized OR 0.88, 95% CI 0.59-1.31, P = .54]) were observed with multivessel PCI.
Overall, staged multivessel PCI improved short- and long-term survival and reduced repeat PCI. Still, large randomized trials are required to confirm the benefits of staged multivessel PCI in STEMI.
接受直接经皮冠状动脉介入治疗（PCI）的 ST 段抬高型心肌梗死（STEMI）和多支血管病变患者通常仅接受罪犯病变的 PCI 治疗。这些患者中完全血运重建策略是否更优尚不清楚。我们进行了一项荟萃分析，比较了 STEMI 患者常规罪犯病变 PCI 与多支血管 PCI 的获益与风险。
从 1996 年至 2011 年 1 月，我们在 MEDLINE、EMBASE、ISI Web of Science 和 The Cochrane Register of Controlled Trials 进行检索。还从 2002 年 1 月至 2011 年 1 月检索相关会议摘要。研究纳入多支血管疾病且接受直接 PCI 的 STEMI 患者。主要终点为长期死亡率。使用固定效应模型对数据进行合并。
在 507 篇引文当中，纳入了 26 项研究（3 项随机对照研究，23 项非随机对照研究；46324 例患者，7886 例行多支血管 PCI，38438 例行罪犯病变 PCI）。多支血管 PCI 与罪犯病变 PCI 的院内死亡率无显著差异（比值比 [OR] 1.11，95%可信区间 [CI] 0.98-1.25，P =.10[随机对照 OR 0.24，95% CI 0.06-0.91，P =.04；非随机对照 OR 1.12，95% CI 1.00-1.27，P =.06]）。然而，如果在指数导管检查期间进行多支血管 PCI，则院内死亡率升高（OR 1.35，95% CI 1.19-1.54，P <.001）。当多支血管 PCI 作为分期手术进行时，院内死亡率较低（OR 0.35，95% CI 0.21-0.59；P <.001；P 交互值<.001）。多支血管 PCI 可降低长期死亡率（OR 0.74，95% CI 0.65-0.85，P <.001[随机对照 OR 0.61，95% CI 0.28-1.33，P =.22；非随机对照 OR 0.75，95% CI 0.65-0.86，P <.001]）和重复 PCI（OR 0.65；95% CI 0.46-0.90，P =.01[随机对照 OR 0.31，95% CI 0.17-0.57，P <.001；非随机对照 OR 0.88，95% CI 0.59-1.31，P =.54]）。
总体而言，分期多支血管 PCI 可改善短期和长期生存率并减少重复 PCI。仍需要大型随机试验来证实分期多支血管 PCI 在 STEMI 中的获益。
