Vaidya Satyanarayana R, Qamar Arman, Arora Sameer, Devarapally Santhosh R, Kondur Ashok, Kaul Prashant
Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville.
Department of Internal Medicine, Campbell University School of Medicine, Lillington, North Carolina.
Coron Artery Dis. 2018 Mar;29(2):151-160. doi: 10.1097/MCA.0000000000000578.
The 2015 American College of Cardiology/American Heart Association update on primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) recommended PCI of the non-infarct-related artery at the time of primary PCI (class IIb recommendation). Despite evidence supporting complete revascularization in STEMI, its benefit on mortality rates is uncertain.
We searched all available databases for randomized controlled trials comparing complete multivessel percutaneous coronary intervention (CMV PCI) with infarct-artery-only revascularization in patients with STEMI. Summary risk ratios and 95% confidence intervals (CIs) were calculated for both the efficacy and safety outcomes.
Nine randomized controlled trials fulfilled the inclusion criteria, yielding 2991 patients. Follow-up periods ranged from 6 to 36 months. Compared with infarct-related artery-only PCI, CMV PCI was associated with significantly lower rates of major adverse cardiac events [relative risk (RR)=0.54, 95% CI=0.41-0.71; P<0.00001], cardiovascular mortality (RR=0.48, 95% CI=0.28-0.80; P=0.005), and repeat revascularization (RR=0.38, 95% CI=0.30-0.47; P<0.00001). Although, contrast-induced nephropathy and major bleed rates were comparable between both groups, CMV PCI failed to show any reduction in all-cause mortality (RR=0.75, 95% CI=0.53-1.07; P=0.11) and nonfatal myocardial infarction (RR=0.69, 95% CI=0.43-1.10; P=0.12).
Our results suggest that in patients with STEMI and multivessel disease, complete revascularization is safe, and is associated with reduced risks of major adverse cardiac events and cardiac death along with a reduced need for repeat revascularization. However, it showed no beneficial effect on all-cause mortality and nonfatal myocardial infarction.
2015年美国心脏病学会/美国心脏协会关于ST段抬高型心肌梗死（STEMI）患者直接经皮冠状动脉介入治疗（PCI）的更新建议在直接PCI时对非梗死相关动脉进行PCI（IIb类推荐）。尽管有证据支持STEMI患者进行完全血运重建，但其对死亡率的益处尚不确定。
我们检索了所有可用数据库，以查找比较STEMI患者完全多支血管经皮冠状动脉介入治疗（CMV PCI）与仅对梗死动脉进行血运重建的随机对照试验。计算了疗效和安全性结局的汇总风险比及95%置信区间（CI）。
9项随机对照试验符合纳入标准，共纳入2991例患者。随访期为6至36个月。与仅对梗死相关动脉进行PCI相比，CMV PCI与显著更低的主要不良心脏事件发生率[相对危险度（RR）=0.54，95%CI=0.41 - 0.71；P<0.00001]、心血管死亡率（RR=0.48，95%CI=0.28 - 0.80；P=0.005）及再次血运重建率（RR=0.38，95%CI=0.30 - 0.47；P<0.00001）相关。虽然两组对比剂诱导的肾病和大出血发生率相当，但CMV PCI在全因死亡率（RR=0.75，95%CI=0.53 - 1.07；P=0.11）和非致命性心肌梗死方面未显示出降低（RR=0.69，95%CI=0.43 - 1.10；P=0.12）。
我们的结果表明，对于STEMI和多支血管病变患者，完全血运重建是安全的，且与降低主要不良心脏事件和心源性死亡风险以及减少再次血运重建需求相关。然而，其对全因死亡率和非致命性心肌梗死未显示出有益作用。
