Department of Medicine, University of Florida, Gainesville, Florida.
Department of Medicine, University of Florida, Gainesville, Florida.
JACC Cardiovasc Interv. 2017 Feb 27;10(4):315-324. doi: 10.1016/j.jcin.2016.11.047.
The authors sought to compare the effectiveness of the different revascularization strategies in ST-segment elevation myocardial infarction (STEMI) patients with multivessel coronary artery disease undergoing primary percutaneous coronary intervention (PCI).
Recent randomized trials have suggested that multivessel complete revascularization at the time of primary percutaneous coronary intervention (PCI) is associated with better outcomes, however; the optimum timing for nonculprit PCI is unknown.
Trials that randomized STEMI patients with multivessel disease to any combination of the 4 different revascularization strategies (i.e., complete revascularization at the index procedure, staged procedure during the hospitalization, staged procedure after discharge or culprit-only revascularization) were included. Random effect risk ratios (RRs) were conducted. Network meta-analysis was constructed using mixed treatment comparison models, and the 4 revascularization strategies were compared.
A total of 10 trials with 2,285 patients were included. In the pairwise meta-analysis, complete revascularization (i.e., at the index procedure or as a staged procedure) was associated with a lower risk of major adverse cardiac events (MACE) (RR: 0.57; 95% confidence interval [CI]: 0.42 to 0.77), due to lower risk of urgent revascularization (RR: 0.44; 95% CI: 0.30 to 0.66). The risk of all-cause mortality (RR: 0.76; 95% CI: 0.52 to 1.12), and spontaneous reinfarction (RR: 0.54; 95% CI: 0.23 to 1.27) was similar. The reduction in the risk of MACE was observed irrespective of the timing of nonculprit artery revascularization in the mixed treatment model.
Current evidence from randomized trials suggests that the risk of all-cause mortality and spontaneous reinfarction is not different among the various revascularization strategies for multivessel disease. Complete revascularization at the index procedure or as a staged procedure (either during the hospitalization or after discharge) was associated with a reduction of MACE due to reduction in urgent revascularization with no difference between these 3 strategies. Future trials are needed to determine the impact of complete revascularization on the risk of all-cause mortality and spontaneous reinfarction.
作者旨在比较急性 ST 段抬高型心肌梗死（STEMI）患者行直接经皮冠状动脉介入治疗（PCI）时，不同血运重建策略的有效性。
最近的随机试验表明，直接 PCI 时行多支血管完全血运重建与更好的结果相关；但是，非罪犯血管 PCI 的最佳时机尚不清楚。
纳入将多支血管疾病的 STEMI 患者随机分配至以下 4 种不同血运重建策略（即指数操作时完全血运重建、住院期间分期操作、出院后分期操作或罪犯血管血运重建）的任何组合的试验。采用随机效应风险比（RR）进行分析。使用混合治疗比较模型进行网络荟萃分析，并对 4 种血运重建策略进行比较。
共纳入 10 项试验，共计 2285 例患者。在成对荟萃分析中，完全血运重建（即在指数操作时或分期操作时）与主要不良心脏事件（MACE）风险降低相关（RR：0.57；95%置信区间[CI]：0.42 至 0.77），这归因于紧急血运重建的风险降低（RR：0.44；95% CI：0.30 至 0.66）。全因死亡率（RR：0.76；95% CI：0.52 至 1.12）和自发性再梗死（RR：0.54；95% CI：0.23 至 1.27）的风险相似。在混合治疗模型中，非罪犯动脉血运重建的时机不同，MACE 风险的降低情况是一致的。
目前来自随机试验的证据表明，对于多支血管疾病，各种血运重建策略的全因死亡率和自发性再梗死风险并无差异。指数操作时或分期操作（住院期间或出院后）的完全血运重建与 MACE 减少相关，这归因于紧急血运重建的减少，而这 3 种策略之间无差异。需要进一步的试验来确定完全血运重建对全因死亡率和自发性再梗死风险的影响。
