Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, University of Pavia, Pavia, Italy.
Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
Can J Cardiol. 2019 Aug;35(8):1047-1057. doi: 10.1016/j.cjca.2019.03.006. Epub 2019 Mar 19.
The optimal strategy and timing of revascularization in hemodynamically stable patients with ST-segment elevation myocardial infarction and multivessel disease is unknown. We performed a systematic review and meta-analysis to explore the comparative efficacy and safety of early complete revascularization vs culprit-only or staged revascularization in this setting.
We searched the literature for randomized clinical trials that assessed this issue. Early complete revascularization was defined as a complete revascularization achieved during the index procedure or within 72 hours. Efficacy outcomes were major adverse cardiovascular events, myocardial infarction, repeat revascularization, and all-cause mortality. Safety outcomes were all bleeding events, stroke, and contrast-induced acute kidney injury.
Nine randomized clinical trials with a total of 2837 patients were included; 1254 received early complete revascularization and 1583 were treated with other revascularization strategies. After a mean follow-up of 15.3 ± 9.4 months early complete revascularization was associated with a lower risk of major adverse cardiovascular events (relative risk [RR], 0.51; 95% confidence interval [CI], 0.41-0.62; P < 0.00001; number needed to treat = 8), myocardial infarction (RR, 0.59; 95% CI, 0.40-0.87), and repeat revascularization (RR, 0.39; 95% CI, 0.28-0.55) without any difference in all-cause mortality and in safety outcomes compared with culprit-only or staged revascularization. Moreover, fractional flow reserve-guided complete revascularization reduced the incidence of repeat revascularization compared with angiography-guided procedure (χ = 4.36; P = 0.04).
Early complete revascularization should be considered in hemodynamically stable patients with ST-segment elevation myocardial infarction and multivessel disease deemed suitable for percutaneous interventions. Fractional flow reserve-guided complete revascularization might be superior to angiography-guided procedures in reducing need for further interventions.
对于血流动力学稳定的 ST 段抬高型心肌梗死伴多支血管病变患者，最佳的血运重建策略和时机尚不清楚。我们进行了一项系统评价和荟萃分析，以探讨在此情况下早期完全血运重建与罪犯血管血运重建或分期血运重建相比的疗效和安全性。
我们检索了评估该问题的随机临床试验文献。早期完全血运重建定义为在指数操作期间或 72 小时内完成的完全血运重建。疗效终点为主要不良心血管事件、心肌梗死、再次血运重建和全因死亡率。安全性终点为所有出血事件、卒中和对比剂诱导的急性肾损伤。
纳入了 9 项随机临床试验，共 2837 例患者；其中 1254 例接受早期完全血运重建，1583 例接受其他血运重建策略。平均随访 15.3±9.4 个月后，早期完全血运重建与较低的主要不良心血管事件风险相关（相对风险 [RR]，0.51；95%置信区间 [CI]，0.41-0.62；P<0.00001；需要治疗的人数[number needed to treat] = 8）、心肌梗死（RR，0.59；95%CI，0.40-0.87）和再次血运重建（RR，0.39；95%CI，0.28-0.55），但全因死亡率和安全性结局与罪犯血管血运重建或分期血运重建无差异。此外，血流储备分数指导的完全血运重建与血管造影指导的操作相比，可降低再次血运重建的发生率（χ²=4.36；P=0.04）。
血流动力学稳定的 ST 段抬高型心肌梗死伴多支血管病变患者，如果适合经皮介入治疗，应考虑早期完全血运重建。血流储备分数指导的完全血运重建可能优于血管造影指导的操作，从而减少进一步介入的需求。
