Ueyama Hiroki A, Akita Keitaro, Kiyohara Yuko, Takagi Hisato, Briasoulis Alexandros, Wiley Jose, Bangalore Sripal, Mehran Roxana, Stone Gregg W, Kuno Toshiki, Bhatt Deepak L
Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA. Electronic address: https://twitter.com/HirokiUeyama.
Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA. Electronic address: https://twitter.com/keitaroakita.
J Am Coll Cardiol. 2025 Jan 7;85(1):19-38. doi: 10.1016/j.jacc.2024.09.1231.
In patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease, most but not all randomized trials have reported that complete revascularization (CR) offers advantages over culprit vessel-only revascularization. In addition, the optimal timing and assessment methods for CR remain undetermined.
The purpose of this study was to identify the optimal revascularization strategy in patients with STEMI and multivessel disease, using a network meta-analysis of randomized controlled trials.
We searched PUBMED and EMBASE for randomized trials evaluating revascularization strategies in patients with STEMI and multivessel disease through July 2024. A network meta-analysis was performed analyzing CR vs culprit vessel-only revascularization as well as the timing of CR (immediate CR vs staged CR). Outcomes were also assessed with 4 CR strategies based on whether revascularization was immediate or staged and whether it was angiographically guided or functionally guided. The primary outcome was major adverse cardiovascular events (MACE).
A total of 26 randomized trials that enrolled 15,902 patients were included. The mean weighted duration of follow-up was 25.2 ± 15.7 months. MACE was reduced with both immediate CR and staged CR compared with culprit-vessel-only treatment (RR: 0.48; 95% CI: 0.36-0.64 and RR: 0.65; 95% CI: 0.52-0.82, respectively), whether with angiographic or functional guidance. Immediate CR was associated with reduced MACE compared with staged CR (RR: 0.74; 95% CI: 0.56-0.97), whether CR was guided angiographically or functionally (RR: 0.77; 95% CI: 0.61-0.99 and RR: 0.49; 95% CI: 0.27-0.89, respectively) caused by reductions in MI. However, when the analysis was restricted to studies that reported both all MI and nonprocedural MI, the benefit of immediate CR in reducing MI compared with staged CR was diminished after excluding procedural MI (RR: 0.44; 95% CI: 0.27-0.71 with procedural MI vs RR: 0.65; 95% CI: 0.36-1.16 without procedural MI).
Among patients with STEMI and multivessel disease, outcomes were better with immediate or staged CR compared with culprit vessel-only treatment, whether with angiographic or functional guidance.
在ST段抬高型心肌梗死（STEMI）和多支冠状动脉疾病患者中，大多数（但并非所有）随机试验报告称，完全血运重建（CR）比仅对罪犯血管进行血运重建具有优势。此外，CR的最佳时机和评估方法仍未确定。
本研究的目的是通过对随机对照试验进行网络荟萃分析，确定STEMI和多支血管疾病患者的最佳血运重建策略。
我们检索了PUBMED和EMBASE，以查找截至2024年7月评估STEMI和多支血管疾病患者血运重建策略的随机试验。进行了一项网络荟萃分析，分析CR与仅对罪犯血管进行血运重建以及CR的时机（即刻CR与分期CR）。还根据血运重建是即刻还是分期以及是血管造影引导还是功能引导，用4种CR策略评估了结局。主要结局是主要不良心血管事件（MACE）。
共纳入26项随机试验，涉及15902例患者。平均加权随访时间为25.2±15.7个月。与仅对罪犯血管进行治疗相比，即刻CR和分期CR均降低了MACE（RR分别为：0.48；95%CI：0.36 - 0.64和RR：0.65；95%CI：0.52 - 0.82），无论采用血管造影引导还是功能引导。与分期CR相比，即刻CR与MACE降低相关（RR：0.74；95%CI：0.56 - 0.97），无论CR是由血管造影引导还是功能引导（RR分别为：0.77；95%CI：0.61 - 0.99和RR：0.49；95%CI：0.27 - 0.89），这是由于心肌梗死（MI）减少所致。然而，当分析仅限于报告了所有MI和非手术性MI的研究时，排除手术性MI后，与分期CR相比，即刻CR在降低MI方面的益处减弱（有手术性MI时RR：0.44；95%CI：0.27 - 0.71，无手术性MI时RR：0.65；95%CI：0.36 - 1.16）。
在STEMI和多支血管疾病患者中，与仅对罪犯血管进行治疗相比，即刻或分期CR的结局更好，无论采用血管造影引导还是功能引导。
