Columbia University Medical Center/New York-Presbyterian Hospital New York NY.
National Heart and Lung Institute Imperial College London London United Kingdom.
J Am Heart Assoc. 2020 Jun 16;9(12):e015263. doi: 10.1161/JAHA.119.015263. Epub 2020 Jun 1.
Background For patients with ST-segment-elevation myocardial infarction (STEMI) and multivessel coronary artery disease, the optimal treatment of the non-infarct-related artery has been controversial. This up-to-date meta-analysis focusing on individual clinical end points was performed to further evaluate the benefit of complete revascularization with percutaneous coronary intervention for patients with STEMI and multivessel coronary artery disease. Methods and Results We systematically identified all randomized trials comparing complete revascularization with percutaneous coronary intervention to culprit-only revascularization for multivessel disease in STEMI and performed a random-effects meta-analysis. The primary efficacy end point was cardiovascular death analyzed on an intention-to-treat basis. Secondary end points included all-cause mortality, myocardial infarction, and unplanned revascularization. Ten studies (7542 patients) were included: 3664 patients were randomized to complete revascularization and 3878 to culprit-only revascularization. Across all patients, complete revascularization was superior to culprit-only revascularization for reduction in the risk of cardiovascular death (relative risk [RR], 0.68; 95% CI, 0.47-0.98; =0.037; I=21.8%) and reduction in the risk of myocardial infarction (RR, 0.65; 95% CI, 0.54-0.79; <0.0001; I=0.0%). Complete revascularization also significantly reduced the risk of unplanned revascularization (RR, 0.37; 95% CI, 0.28-0.51; <0.0001; I=64.7%). The difference in all-cause mortality with percutaneous coronary intervention was not statistically significant (RR, 0.85; 95% CI, 0.69-1.04; =0.108; I=0.0%). Conclusions For patients with STEMI and multivessel disease, complete revascularization with percutaneous coronary intervention significantly improves hard clinical outcomes including cardiovascular death and myocardial infarction. These data have implications for clinical practice guidelines regarding recommendations for complete revascularization following STEMI.
对于 ST 段抬高型心肌梗死（STEMI）和多支冠状动脉疾病患者，非梗死相关动脉的最佳治疗方法一直存在争议。本研究旨在通过针对个体临床终点的最新荟萃分析，进一步评估经皮冠状动脉介入治疗对 STEMI 和多支冠状动脉疾病患者完全血运重建的获益。
我们系统地检索了所有比较多支血管病变 STEMI 患者完全血运重建与罪犯血管血运重建的随机试验，并进行了随机效应荟萃分析。主要疗效终点为意向治疗基础上的心血管死亡。次要终点包括全因死亡率、心肌梗死和计划外血运重建。共纳入 10 项研究（7542 例患者）：3664 例患者被随机分配至完全血运重建组，3878 例患者被随机分配至罪犯血管血运重建组。所有患者中，完全血运重建组心血管死亡风险降低（相对风险 [RR]，0.68；95%置信区间 [CI]，0.47-0.98；=0.037；I²=21.8%）和心肌梗死风险降低（RR，0.65；95%CI，0.54-0.79；<0.0001；I²=0.0%）优于罪犯血管血运重建组。完全血运重建还显著降低了计划外血运重建的风险（RR，0.37；95%CI，0.28-0.51；<0.0001；I²=64.7%）。经皮冠状动脉介入治疗的全因死亡率差异无统计学意义（RR，0.85；95%CI，0.69-1.04；=0.108；I²=0.0%）。
对于 STEMI 和多支血管疾病患者，经皮冠状动脉介入治疗完全血运重建可显著改善包括心血管死亡和心肌梗死在内的硬临床结局。这些数据对 STEMI 后完全血运重建的临床实践指南推荐具有重要意义。
