El-Hayek Georges E, Gershlick Anthony H, Hong Mun K, Casso Dominguez Abel, Banning Amerjeet, Afshar Arash Ehteshami, Herzog Eyal, Tamis-Holland Jacqueline E
Department of Cardiology, Mount Sinai Saint Luke's Hospital, New York, New York.
NIHR Leicester Cardiovascular Biomedical Research Unit, University of Leicester, Leicester, United Kingdom.
Am J Cardiol. 2015 Jun 1;115(11):1481-6. doi: 10.1016/j.amjcard.2015.02.046. Epub 2015 Mar 12.
Current guidelines recommend against revascularization of the noninfarct artery during the index percutaneous coronary intervention (PCI) in hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI). This was based largely on observational studies with few data coming from randomized controlled trials (RCTs). Recently, several small-to-moderate sized RCTs have provided data, suggesting that a multivessel revascularization approach may be appropriate. We performed a meta-analysis of RCTs comparing multivessel percutaneous coronary intervention (MV PCI) versus culprit vessel-only revascularization (COR) during primary PCI in patients with STEMI and multivessel coronary disease (MVCD). We searched Medline, PubMed, and Scopus databases for RCTs comparing MV PCI versus COR in patients with STEMI and MVCD. The incidence of all-cause death, cardiac death, recurrent myocardial infarction, and revascularization during follow-up were extracted. Four RCTs fit our primary selection criteria. Among these, 566 patients underwent MV PCI (either at the time of the primary PCI or as a staged procedure) and 478 patients underwent COR. During long-term follow-up (range 1 to 2.5 years), combined data indicated a significant reduction in all-cause mortality (relative risk [RR] 0.57, 95% confidence interval [CI] 0.36 to 0.92, p = 0.02) and in cardiac death (RR 0.38, 95% CI 0.20 to 0.73, p = 0.004) with MV PCI. In addition, there was a significantly lower risk of recurrent myocardial infarction (RR 0.41, 95% CI 0.23 to 0.75; p = 0.004) and future revascularization (RR 0.37, 95% CI 0.27 to 0.52; p <0.00001). In conclusion, from the RCT data, MV PCI appears to improve outcomes in patients with STEMI and MVCD.
目前的指南建议，对于血流动力学稳定的ST段抬高型心肌梗死（STEMI）患者，在首次经皮冠状动脉介入治疗（PCI）期间，不应对非梗死相关动脉进行血运重建。这主要基于观察性研究，来自随机对照试验（RCT）的数据很少。最近，几项中小型RCT提供了数据，表明多支血管血运重建方法可能是合适的。我们对RCT进行了一项荟萃分析，比较STEMI合并多支冠状动脉疾病（MVCD）患者在直接PCI期间多支血管经皮冠状动脉介入治疗（MV PCI）与仅对罪犯血管进行血运重建（COR）的效果。我们在Medline、PubMed和Scopus数据库中搜索比较STEMI合并MVCD患者MV PCI与COR的RCT。提取随访期间全因死亡、心源性死亡、再发心肌梗死和血运重建的发生率。四项RCT符合我们的主要入选标准。其中，566例患者接受了MV PCI（在直接PCI时或作为分期手术），478例患者接受了COR。在长期随访（1至2.5年）期间，合并数据表明MV PCI可显著降低全因死亡率（相对危险度[RR]0.57，95%置信区间[CI]0.36至0.92，p = 0.02）和心源性死亡（RR 0.38，95%CI 0.20至0.73，p = 0.004）。此外，再发心肌梗死（RR 0.41，95%CI 0.23至0.75；p = 0.004）和未来血运重建（RR 0.37，95%CI 0.27至0.52；p < ；0.00001）的风险也显著降低。总之，根据RCT数据，MV PCI似乎可改善STEMI合并MVCD患者的预后。
