Chen Yi, Li Meng, Wu Yanqing
The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China.
Front Cardiovasc Med. 2024 Aug 9;11:1389017. doi: 10.3389/fcvm.2024.1389017. eCollection 2024.
The optimal timing for nonculprit vascular reconstruction surgery in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary disease (MVD) is still controversial. Our aim was to explore the optimal intervention time for percutaneous coronary intervention (PCI) in STEMI patients who underwent MVD.
The PubMed/Medline, EMBASE, Cochrane Library, and ClinicalTrials.gov databases were searched from inception to January 1, 2024 for clinical studies comparing immediate multivessel PCI and staged multivessel PCI in patients with STEMI. The primary outcomes were death from any cause, cardiovascular death, noncardiac death, myocardial infarction (MI) and unplanned ischemia-driven revascularization. The secondary outcomes were ischemic stroke, stent thrombosis, renal dysfunction and major bleeding. The risk ratios (RRs) and odds ratios (ORs) were calculated with fixed-effects models and random-effects models, and 95% confidence intervals (CIs) were calculated.
Five randomized trials with 2,782 patients and six prospective observational studies with 3,131 patients were selected for inclusion in this meta-analysis. The staged PCI group had significantly lower pooled RRs for myocardial infarction (0.43, 95% = 0.27-0.67; = 0.0002) and unplanned ischemia-driven revascularization (0.57, 95% = 0.41-0.78; = 0.0004). There were no significant differences in any cause of death, cardiovascular cause of death, or noncardiac cause of death. However, the results of prospective observational studies in the real world indicated that the staged PCI group had significantly lower pooled ORs for all-cause mortality (2.30, 95% = 1.22-4.34; = 0.01), cardiovascular death (2.29, 95% = 1.10-4.77; = 0.03), and noncardiovascular death (3.46, 95% = 1.40-8.56; = 0.007).
According to our randomized trial analysis, staged multivessel PCI significantly reduces the risk of myocardial infarction and unplanned ischemia-driven revascularization compared to immediate multivessel PCI. There was no significant difference between the two groups in terms of all-cause mortality, cardiovascular mortality, or noncardiovascular mortality risk. However, prospective non-randomized studies suggest there might be a benefit in mortality in the staged PCI group. Therefore, staged multivessel PCI may be the optimal PCI strategy for STEMI patients with MVD.
ST段抬高型心肌梗死（STEMI）合并多支冠状动脉疾病（MVD）患者非罪犯血管重建手术的最佳时机仍存在争议。我们的目的是探讨接受MVD的STEMI患者经皮冠状动脉介入治疗（PCI）的最佳干预时间。
检索PubMed/Medline、EMBASE、Cochrane图书馆和ClinicalTrials.gov数据库，从建库至2024年1月1日，查找比较STEMI患者即刻多支血管PCI和分期多支血管PCI的临床研究。主要结局为任何原因导致的死亡、心血管死亡、非心血管死亡、心肌梗死（MI）和非计划缺血驱动的血运重建。次要结局为缺血性卒中、支架血栓形成、肾功能不全和大出血。采用固定效应模型和随机效应模型计算风险比（RRs）和比值比（ORs），并计算95%置信区间（CIs）。
五项随机试验纳入2782例患者，六项前瞻性观察性研究纳入3131例患者，纳入本荟萃分析。分期PCI组心肌梗死的合并RRs显著较低（0.43，95%CI = 0.27 - 0.67；P = 0.0002），非计划缺血驱动的血运重建的合并RRs也显著较低（0.57，95%CI = 0.41 - 0.78；P = 0.0004）。任何原因导致的死亡、心血管原因导致的死亡或非心血管原因导致的死亡均无显著差异。然而，现实世界中的前瞻性观察性研究结果表明，分期PCI组全因死亡率的合并ORs显著较低（2.30，95%CI = 1.22 - 4.34；P = 0.01），心血管死亡的合并ORs显著较低（2.29，95%CI = 1.10 - 4.77；P = 0.03），非心血管死亡的合并ORs显著较低（3.46，95%CI = 1.40 - 8.56；P = 0.007）。
根据我们的随机试验分析，与即刻多支血管PCI相比，分期多支血管PCI显著降低心肌梗死和非计划缺血驱动的血运重建风险。两组在全因死亡率、心血管死亡率或非心血管死亡率风险方面无显著差异。然而，前瞻性非随机研究表明，分期PCI组可能在死亡率方面有获益。因此，分期多支血管PCI可能是MVD的STEMI患者的最佳PCI策略。
