Shah Rahman, Berzingi Chalak, Mumtaz Mubashir, Jasper John B, Goswami Rohan, Morsy Mohamed S, Ramanathan Kodangudi B, Rao Sunil V
Section of Cardiology, School of Medicine, University of Tennessee, Memphis, Tennessee; Veterans Affairs Medical Center, Memphis, Tennessee.
West Virginia University Heart Institute, Morgantown, West Virginia.
Am J Cardiol. 2016 Nov 15;118(10):1466-1472. doi: 10.1016/j.amjcard.2016.08.009. Epub 2016 Aug 23.
Several recent randomized controlled trials (RCTs) demonstrated better outcomes with multivessel complete revascularization (CR) than with infarct-related artery-only revascularization (IRA-OR) in patients with ST-segment elevation myocardial infarction. It is unclear whether CR should be performed during the index procedure (IP) at the time of primary percutaneous coronary intervention (PCI) or as a staged procedure (SP). Therefore, we performed a pairwise meta-analysis using a random-effects model and network meta-analysis using mixed-treatment comparison models to compare the efficacies of 3 revascularization strategies (IRA-OR, CR-IP, and CR-SP). Scientific databases and websites were searched to find RCTs. Data from 9 RCTs involving 2,176 patients were included. In mixed-comparison models, CR-IP decreased the risk of major adverse cardiac events (MACEs; odds ratio [OR] 0.36, 95% CI 0.25 to 0.54), recurrent myocardial infarction (MI; OR 0.50, 95% CI 0.24 to 0.91), revascularization (OR 0.24, 95% CI 0.15 to 0.38), and cardiovascular (CV) mortality (OR 0.44, 95% CI 0.20 to 0.87). However, only the rates of MACEs, MI, and CV mortality were lower with CR-SP than with IRA-OR. Similarly, in direct-comparison meta-analysis, the risk of MI was 66% lower with CR-IP than with IRA-OR, but this advantage was not seen with CR-SP. There were no differences in all-cause mortality between the 3 revascularization strategies. In conclusion, this meta-analysis shows that in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease, CR either during primary PCI or as an SP results in lower occurrences of MACE, revascularization, and CV mortality than IRA-OR. CR performed during primary PCI also results in lower rates of recurrent MI and seems the most efficacious revascularization strategy of the 3.
最近的几项随机对照试验（RCT）表明，在ST段抬高型心肌梗死患者中，多支血管完全血运重建（CR）比仅梗死相关动脉血运重建（IRA-OR）的预后更好。目前尚不清楚CR是应在初次经皮冠状动脉介入治疗（PCI）时的初次手术（IP）期间进行，还是作为分期手术（SP）进行。因此，我们使用随机效应模型进行了成对荟萃分析，并使用混合治疗比较模型进行了网络荟萃分析，以比较三种血运重建策略（IRA-OR、CR-IP和CR-SP）的疗效。检索了科学数据库和网站以查找RCT。纳入了9项涉及2176例患者的RCT数据。在混合比较模型中，CR-IP降低了主要不良心脏事件（MACE）的风险（比值比[OR]0.36，95%CI 0.25至0.54）、再发心肌梗死（MI；OR 0.50，95%CI 0.24至0.91）、血运重建（OR 0.24，95%CI 0.15至0.38）和心血管（CV）死亡率（OR 0.44，95%CI 0.20至0.87）。然而，只有CR-SP的MACE、MI和CV死亡率低于IRA-OR。同样，在直接比较荟萃分析中，CR-IP的MI风险比IRA-OR低66%，但CR-SP未显示出这一优势。三种血运重建策略在全因死亡率方面没有差异。总之，这项荟萃分析表明，在ST段抬高型心肌梗死和多支冠状动脉疾病患者中，无论是在初次PCI期间还是作为分期手术进行CR，与IRA-OR相比，MACE、血运重建和CV死亡率的发生率更低。在初次PCI期间进行CR还可降低再发MI的发生率，似乎是三种血运重建策略中最有效的。
