Guo Wen-Qin, Li Lang, Su Qiang, Sun Yu-Han, Wang Xian-Tao, Dai Wei-Ran, Li Hong-Qing
Department of Cardiology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China,
Clin Epidemiol. 2018 Aug 24;10:1037-1051. doi: 10.2147/CLEP.S167138. eCollection 2018.
The optimal revascularization strategy for patients with ST-segment elevation myocardial infarction and multivessel disease is unclear. In this study, we performed a meta-analysis to determine the optimal revascularization strategy for treating these patients.
Searches of PubMed, the Cochrane Library, clinicaltrial.gov, and the reference lists of relevant papers were performed covering the period between the year 2000 and March 20, 2017. A pairwise analysis and a Bayesian network meta-analysis were performed to compare the effectiveness of early complete revascularization (CR) during the index hospitalization, delayed CR, and culprit only revascularization (COR). The primary endpoint was the incidence of major adverse cardiac events (MACE), which were defined as the composite of recurrent myocardial infarction (MI), repeat revascularization, and all-cause mortality. The secondary endpoints were the rates of all-cause mortality, recurrent MI, and repeat revascularization. This study is registered at PROSPERO under registration number CRD42017059980.
Eleven randomized controlled trials including a total of 3,170 patients were identified. A pairwise meta-analysis showed that compared with COR, early CR was associated with significantly decreased risks of MACE (relative risk [RR] 0.47, 95% CI 0.39-0.56), MI (RR 0.55, 95% CI 0.37-0.83), and repeat revascularization (RR 0.35, 95% CI 0.27-0.46) but not of all-cause mortality (RR 0.78, 95% CI 0.52-1.16). These results were confirmed by trial sequential analysis. The network meta-analysis showed that early CR had the highest probability of being the first treatment option during MACE (89.2%), MI (83.3%), and repeat revascularization (80.4%).
Early CR during the index hospitalization was markedly superior to COR with respect to reducing the risk of MACE, as CR significantly decreased the risks of MI and repeat revascularization compared with COR. However, further study is warranted to determine whether CR during the index hospitalization can improve survival in patients with concurrent ST-segment elevation myocardial infarction and multivessel disease. The optimal timing of CR remains inconclusive considering the small number of studies and patients included in the analysis comparing early and delayed CR.
ST段抬高型心肌梗死合并多支血管病变患者的最佳血运重建策略尚不清楚。在本研究中，我们进行了一项荟萃分析，以确定治疗这些患者的最佳血运重建策略。
检索了PubMed、Cochrane图书馆、clinicaltrial.gov以及相关论文的参考文献列表，涵盖2000年至2017年3月20日期间。进行了成对分析和贝叶斯网络荟萃分析，以比较首次住院期间早期完全血运重建（CR）、延迟CR和仅罪犯血管血运重建（COR）的有效性。主要终点是主要不良心脏事件（MACE）的发生率，其定义为复发性心肌梗死（MI）、再次血运重建和全因死亡率的综合。次要终点是全因死亡率、复发性MI和再次血运重建的发生率。本研究已在PROSPERO注册，注册号为CRD42017059980。
确定了11项随机对照试验，共纳入3170例患者。成对荟萃分析显示，与COR相比，早期CR与MACE风险显著降低相关（相对风险[RR]0.47，95%CI 0.39-0.56）、MI（RR 0.55，95%CI 0.37-0.83）和再次血运重建（RR 0.35，95%CI 0.27-0.46），但与全因死亡率无关（RR 0.78，95%CI 0.52-1.16）。这些结果通过试验序贯分析得到证实。网络荟萃分析显示，早期CR在MACE（89.2%）、MI（83.3%）和再次血运重建（80.4%）期间作为首选治疗方案的概率最高。
在首次住院期间进行早期CR在降低MACE风险方面明显优于COR，因为与COR相比，CR显著降低了MI和再次血运重建的风险。然而仍需要进一步研究以确定首次住院期间的CR是否能改善ST段抬高型心肌梗死合并多支血管病变患者生存率。考虑到比较早期和延迟CR的分析中纳入的研究和患者数量较少，CR的最佳时机仍无定论。
