Fatima Shumail, Harinstein Matthew E, Hussain Mubashir, Pacella John J
Harrington Heart and Vascular Institute, University Hospitals, Case Western Reserve Medical University, United States.
Heart and Vascular Institute, University of Pittsburgh Medical Center, United States.
Cardiovasc Revasc Med. 2025 Sep;78:1-9. doi: 10.1016/j.carrev.2024.12.014. Epub 2024 Dec 29.
There exists clinical equipoise regarding whether and when an invasive approach should be preferred over conservative treatment in the management of stable late ST-elevation myocardial infarction (STEMI) presenting within 12 to 72 h of symptom onset.
To perform a systematic review to identify the most effective treatment strategy between percutaneous coronary intervention (PCI) and medical therapy in stable late STEMI presenters by comparing their respective outcomes as well as determine the optimal timing of PCI by evaluating the outcomes of urgent versus non-urgent PCI approach in this patient population.
PubMed, Embase, and Cochrane databases were queried from inception until March 2024 for studies comparing the outcomes of PCI versus medical therapy, as well as urgent versus non-urgent PCI, in stable late STEMI patients presenting with symptom onset within 12-72 h. Quality of the studies and risk of bias were assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria and the Cochrane Risk of Bias (ROBINS-I 2016) tool, respectively.
A total of 8 studies were included in this systematic review that met the inclusion criteria. Among these, 5 studies (1 randomized controlled trial (RCT), 1 post-hoc analysis, and 3 observational studies) with an aggregate of 3820 participants compared PCI and medical therapy in stable late STEMI presenters. They found that PCI was associated with statistically significant better short- and long-term outcomes by lowering all-cause mortality, recurrent myocardial infarction (MI), and infarct size, and by improving myocardial salvage index (P < 0.001). Similarly, a non-statistically significant improvement was seen in the events of cardiac death, heart failure, and revascularization as well as ejection fraction percentage with PCI (P > 0.05). The other 3 studies, involving 1270 participants, were observational and compared urgent versus non-urgent PCI and did not find any statistically significant difference in clinical outcomes between the two approaches (P > 0.05). The included studies were significantly heterogeneous in methodologies, follow-up intervals, and reporting of outcomes. Most of the studies provided moderate quality of evidence and had moderate to serious risk of bias.
Revascularization through PCI is associated with superior short- and long-term outcomes compared to medical therapy in stable late STEMI patients presenting within 12-72 h of symptom onset. However, the optimal timing of PCI needs further investigation.
对于症状出现后12至72小时内就诊的稳定型晚期ST段抬高型心肌梗死（STEMI）患者，在管理中是否以及何时应优先采用侵入性治疗方法而非保守治疗，临床上存在 equipoise 。
进行系统评价，通过比较经皮冠状动脉介入治疗（PCI）和药物治疗各自的结果，确定稳定型晚期STEMI患者中最有效的治疗策略，并通过评估该患者群体中紧急PCI与非紧急PCI方法的结果来确定PCI的最佳时机。
从数据库建立至2024年3月，检索PubMed、Embase和Cochrane数据库，以查找比较PCI与药物治疗以及紧急PCI与非紧急PCI在症状出现后12 - 72小时内就诊的稳定型晚期STEMI患者中的结果的研究。分别使用推荐分级、评估、制定和评价（GRADE）标准以及Cochrane偏倚风险（ROBINS - I 2016）工具评估研究质量和偏倚风险。
本系统评价共纳入8项符合纳入标准的研究。其中，5项研究（1项随机对照试验（RCT）、1项事后分析和3项观察性研究）共3820名参与者比较了稳定型晚期STEMI患者的PCI和药物治疗。他们发现，PCI通过降低全因死亡率、复发性心肌梗死（MI）和梗死面积，并提高心肌挽救指数，在短期和长期结果方面具有统计学意义上的显著优势（P < 0.001）。同样，PCI在心脏死亡、心力衰竭、血运重建事件以及射血分数百分比方面也有非统计学意义上的改善（P > 0.05）。另外3项研究涉及1270名参与者，为观察性研究，比较了紧急PCI与非紧急PCI，未发现两种方法在临床结果上有任何统计学意义上的差异（P > 0.05）。纳入的研究在方法、随访间隔和结果报告方面存在显著异质性。大多数研究提供的证据质量中等，且存在中度至严重的偏倚风险。
对于症状出现后12至72小时内就诊的稳定型晚期STEMI患者，与药物治疗相比，通过PCI进行血运重建具有更好的短期和长期结果。然而，PCI的最佳时机需要进一步研究。
