Bajaj Navkaranbir S, Kalra Rajat, Aggarwal Himanshu, Ather Sameer, Gaba Saurabh, Arora Garima, McGiffin David C, Ahmed Mustafa, Aslibekyan Stella, Arora Pankaj
Division of Cardiology, Department of Medicine, University of Alabama at Birmingham, AL (N.S.B., H.A., S.A., S.G., G.A., M.A., P.A.) Ryals School of Public Health, Department of Epidemiology, University of Alabama at Birmingham, AL (N.S.B., S.A.).
Department of Medicine, University of Alabama at Birmingham, AL (R.K.).
J Am Heart Assoc. 2015 Dec 14;4(12):e002540. doi: 10.1161/JAHA.115.002540.
Significant controversy exists regarding the best approach for nonculprit vessel revascularization in patients with multivessel coronary artery disease presenting with ST-segment elevation myocardial infarction. We conducted a systematic investigation to pool data from current randomized controlled trials (RCTs) to assess optimal treatment strategies in this patient population.
A comprehensive search of SCOPUS from inception through May 2015 was performed using predefined criteria. We compared efficacy and safety outcomes of different approaches by categorizing the studies into 3 groups: (1) complete revascularization (CR) versus culprit lesion revascularization (CL) at index hospitalization, (2) CR at index hospitalization versus staged revascularization (SR) of nonculprit vessels at a separate hospitalization, and (3) comparison of SR versus CL. Eight eligible RCTs met the inclusion criteria: (1) CR versus CL (6 RCTs, n=1727) (2) CR versus SR (3 RCTs, n=311), and (3) SR versus CL (1 RCT, n=149). We observed significantly lower rates of major adverse cardiovascular events, revascularization, and repeat percutaneous coronary interventions among patients treated with CR and SR compared with a CL approach (P<0.05). The rates of all-cause mortality, cause-specific mortality, major bleeding, reinfarction, stroke, and contrast-induced nephropathy did not differ in the CR arm compared with the CL arm. The rates of these outcomes were similar in the CR and SR arms.
Results suggest that CR and SR compared with CL reduce major adverse cardiovascular event and revascularization rates primarily by lowering repeated percutaneous coronary intervention rates. We did not observe any increase in the rate of adverse events while using a CR or SR strategy compared with a CL approach. Current guidelines discouraging CR need to be reevaluated, and clinical judgment should prevail in treating multivessel coronary artery disease patients with ST-segment elevation myocardial infarction as data from larger RCTs accumulate.
对于ST段抬高型心肌梗死合并多支冠状动脉疾病患者的非罪犯血管血运重建的最佳方法存在重大争议。我们进行了一项系统研究，汇总当前随机对照试验（RCT）的数据，以评估该患者群体的最佳治疗策略。
使用预定义标准对SCOPUS从创刊至2015年5月进行全面检索。我们将研究分为三组比较不同方法的疗效和安全性结果：（1）首次住院时完全血运重建（CR）与罪犯病变血运重建（CL），（2）首次住院时CR与非罪犯血管在单独住院时的分期血运重建（SR），以及（3）SR与CL的比较。八项符合条件的RCT满足纳入标准：（1）CR与CL（6项RCT，n = 1727），（2）CR与SR（3项RCT，n = 311），以及（3）SR与CL（1项RCT，n = 149）。我们观察到，与CL方法相比，接受CR和SR治疗的患者发生主要不良心血管事件、血运重建和重复经皮冠状动脉介入治疗的发生率显著降低（P<0.05）。CR组与CL组相比，全因死亡率、特定病因死亡率、大出血、再梗死、中风和造影剂肾病的发生率没有差异。这些结果在CR组和SR组中相似。
结果表明，与CL相比，CR和SR主要通过降低重复经皮冠状动脉介入治疗率来降低主要不良心血管事件和血运重建率。与CL方法相比，使用CR或SR策略时，我们未观察到不良事件发生率有任何增加。随着来自更大规模RCT的数据积累，目前不鼓励CR的指南需要重新评估，并且在治疗ST段抬高型心肌梗死合并多支冠状动脉疾病患者时应优先考虑临床判断。
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