Multivessel Percutaneous Coronary Intervention Strategy Research Articles

Culprit-only versus immediate multi-vessel revascularization in patients with AMI complicated by advanced cardiogenic shock undergoing VA-ECMO

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): This study was supported by unrestricted grants from the Korean Society of Interventional Cardiology. Aims Despite the benefit of culprit-only percutaneous coronary intervention (PCI) in the CULPRIT-SHOCK trial, the optimal revascularization strategy for a refractory cardiogenic shock (CS) requiring mechanical circulatory support devices remains controversial. This study aimed to compare clinical outcomes between the culprit-only and immediate multi-vessel PCI strategies in patients with acute myocardial infarction (AMI) complicated by CS who underwent venoarterial-extracorporeal membrane oxygenation (VA-ECMO). Methods and Results This study was patient-pooled data from the RESCUE and SMC-ECMO registries. A total of 408 AMI patients with multi-vessel disease who underwent VA-ECMO due to refractory CS were included in this analysis. The study population was classified into culprit-only versus immediate multi-vessel PCI according to non-culprit lesion (NCL) treatment strategies. The co-primary endpoints were 30-day mortality or renal-replacement therapy and 12-month follow-up mortality. Among the study population, 241 (59.1%) underwent culprit-only PCI and 167 (40.9%) underwent immediate multi-vessel PCI. Compared with culprit-only PCI, immediate multi-vessel PCI was associated with significantly lower risks of 30-day mortality or renal-replacement therapy (66.8% vs. 54.5%, p=0.02) and all-cause mortality during 12 months of follow-up (59.5% vs. 47.8%, hazard ratio [HR] 0.70; 95% confidence interval [CI] 0.53–0.92, p=0.01) in patients with AMI and CS who underwent VA-ECMO. These results were also consistent in the 290 pairs of propensity score-matched population (55.6% vs. 46.1%, HR 0.71; 95% CI 0.51–0.98, p=0.04). Conclusion Among AMI patients with multi-vessel disease complicated by advanced CS, immediate multi-vessel PCI might be associated with improved clinical outcomes in those undergoing VA-ECMO.

Multivessel vs. culprit-only percutaneous coronary intervention strategy in older adults with acute myocardial infarction

BackgroundThe optima revascularization strategy for senior patients admitted with acute myocardial infarction (AMI) in the context of multivessel coronary artery disease (MVCAD) remains unclear. We aimed to compare a strategy of culprit-vessel (CV) vs. multi-vessel percutaneous coronary intervention (MV-PCI) in older adults (≥75 years) with AMI. MethodsWe analyzed four randomized controlled trials designed to include older adults with AMI. The primary endpoint was all-cause death. The secondary endpoint was the composite of all-cause death, myocardial infarction, stroke and major bleeding (Net Adverse Clinical Events, NACE). A non-parsimonious propensity score and nearest-neighbor matching was performed to account for bias. ResultsA total of 1,334 trial participants were included; of them, 770 (57.7%) underwent CV-PCI and 564 (42.3%) a MV-PCI strategy. After a median follow-up of 365 days, patients treated with MV-PCI experienced a lower rate of death (6.0% vs. 9.9%; p = 0.01) and of NACE (11.2% vs. 15.5%; p = 0.016). After multivariable analysis, MV-PCI was independently associated with a lower hazard of death (hazard ratio [HR]: 0.65; 95% confidence interval [CI]: 0.42–0.96; p = 0.03) and NACE (NACE 0.72[0.53–0.98]; p = 0.04). These results were confirmed in a matched propensity analysis, were consistent throughout the spectrum of older age and when analyzed by subgroups and when immortal-time bias was considered. ConclusionsIn the setting of older adults with MVCAD who were managed invasively for AMI, a MV-PCI strategy to pursue complete revascularization was associated with better survival and lower risk of NACE compared to a CV-PCI. Adequately sized RCTs are required to confirm these findings.

Abstract 14477: Meta-Analysis of Studies Comparing Multivessel Percutaneous Coronary Intervention and Culprit Vessel Only Intervention Among Patients With Acute Myocardial Infarction and Cardiogenic Shock

Background: Studies investigating mortality and adverse event outcomes in patients presenting with acute myocardial infarction (MI) in cardiogenic shock (CS) have reported conflicting results, and have primarily included patients with ST elevation MI. This meta-analysis investigates appropriate revascularization strategy in these patients. Methods: PubMed, Google Scholar, CINAHL and Cochrane databases were queried for studies comparing multivessel (MV) percutaneous coronary intervention (PCI) and culprit vessel (CV) PCI in patients with MI in CS. Data on outcomes from the selected studies were extracted and analyzed by means of random effects model. Two tailed p-value less than 0.05 was considered significant. Heterogeneity was assessed using I 2 test. Results: Twelve studies were included in the final analysis. There was no significant difference in short-term (OR 0.95, 95% CI [0.90-1.01]; p=0.09) or long-term (1.16 [0.95-1.41]; p=0.14) mortality between MV PCI and CV PCI ( Figure) . Similarly, the odds of reinfarction (1.04 [0.58-1.85]; p=0.90) and stroke (1.08 [0.88-1.33]; p=0.46) were similar between the two groups. Although patients with MV PCI had lower odds of revascularization (0.46 [0.34-0.62]; p<0.01), they carried higher odds of new renal replacement therapy (1.30 [1.14-1.48]; p<0.01) and bleeding (1.25 [1.14-1.36]; p<0.01). Interestingly, on exclusion of study exclusively containing patients with non-ST elevation MI, odds of short-term mortality were higher (1.44 [1.28-1.62]; p<0.01) in the MV PCI group. Conclusions: Among patients with AMI and cardiogenic shock, there was no difference observed in short-term or long-term all-cause mortality, between MV PCI and CV PCI revascularization strategies. However, adopting the MV PCI strategy may lead to higher odds of bleeding and renal replacement therapy.

Predictive Value of the Residual SYNTAX Score in Patients With Cardiogenic Shock

BackgroundIn hemodynamically stable patients, complete revascularization (CR) following percutaneous coronary intervention (PCI) is associated with a better prognosis in chronic and acute coronary syndromes. ObjectivesThis study sought to assess the extent, severity, and prognostic value of remaining coronary stenoses following PCI, by using the residual SYNTAX score (rSS), in patients with cardiogenic shock (CS) related to myocardial infarction (MI). MethodsThe CULPRIT-SHOCK (Culprit Lesion Only Percutaneous Coronary Intervention [PCI] Versus Multivessel PCI in Cardiogenic Shock) trial compared a multivessel PCI (MV-PCI) strategy with a culprit lesion–only PCI (CLO-PCI) strategy in patients with multivessel coronary artery disease who presented with MI-related CS. The rSS was assessed by a central core laboratory. The study group was divided in 4 subgroups according to tertiles of rSS of the participants, thereby isolating patients with an rSS of 0 (CR). The predictive value of rSS for the 30-day primary endpoint (mortality or severe renal failure) and for 30-day and 1-year mortality was assessed using multivariate logistic regression. ResultsAmong the 587 patients with an rSS available, the median rSS was 9.0 (interquartile range: 3.0 to 17.0); 102 (17.4%), 100 (17.0%), 196 (33.4%), and 189 (32.2%) patients had rSS = 0, 0 < rSS ≤5, 5 < rSS ≤14, and rSS >14, respectively. CR was achieved in 75 (25.2%; 95% confidence interval [CI]: 20.3% to 30.5%) and 27 (9.3%; 95% CI: 6.2% to 13.3%) of patients treated using the MV-PCI and CLO-PCI strategies, respectively. After multiple adjustments, rSS was independently associated with 30-day mortality (adjusted odds ratio per 10 units: 1.49; 95% CI: 1.11 to 2.01) and 1-year mortality (adjusted odds ratio per 10 units: 1.52; 95% CI: 1.11 to 2.07). ConclusionsAmong patients with multivessel disease and MI-related CS, CR is achieved only in one-fourth of the patients treated using an MV-PCI strategy. and the residual SYNTAX score is independently associated with early and late mortality.

Impact of chronic total occlusion and revascularization strategy in patients with infarct-related cardiogenic shock: A subanalysis of the culprit-shock trial

The impact of coronary artery chronic total occlusion (CTO) and its management with percutaneous coronary intervention (PCI) in the setting of myocardial infarction (MI) related cardiogenic shock (CS) remains unclear. This is a pre-specified analysis from the culprit-lesion-only PCI vs multivessel PCI in CS (CULPRIT-SHOCK) trial which randomized patients presenting with MI and multivessel disease complicated by CS to a culprit-lesion-only or immediate multivessel PCI strategy. CTO was defined by central core-laboratory evaluation. The independent associations between the presence of CTO and adverse outcomes at 30 days and 1 year were assessed using multivariate logistics models. A noninfarct related CTO was present in 157 of 667 (23.5%) analyzed patients. Patients presenting with CTO had more frequent diabetes mellitus or prior PCI but less frequently presented with ST segment elevation MI as index event. The presence of CTO was associated with higher rate of death at 30 days (adjusted Odds ratio 1.63; 95% confidence interval [CI] 1.01-2.60). Rate of death at 1 year was also increased but did not reach statistical significance (adjusted Odds ratio 1.62; 95%CI 0.99-2.66). Compare to immediate multivessel PCI, a strategy of culprit-lesion-only PCI was associated with lower rates of death or renal replacement therapy at 30 days in patients with and without CTO (Odds ratio 0.79 95%CI 0.42-1.49 and Odds ratio 0.67 95%CI 0.48-0.96, respectively), without significant interaction (P = .68). In patients with MI-related CS and multivessel disease, the presence of CTO is associated with adverse outcomes while a strategy of culprit-lesion-only PCI seems beneficial regardless of the presence of CTO.

Multivessel Versus Culprit-Only Revascularization in STEMI and Multivessel Coronary Artery Disease: Meta-Analysis of Randomized Trials

ObjectivesThe goal of this systematic review and meta-analysis was to provide a comprehensive evaluation of contemporary randomized trials addressing the efficacy and safety of multivessel versus culprit vessel–only percutaneous coronary intervention (PCI) among patients presenting with ST-segment elevation myocardial infarction and multivessel coronary artery disease. BackgroundMultivessel coronary artery disease is present in about one-half of patients with ST-segment elevation myocardial infarction. Randomized controlled trials comparing multivessel and culprit vessel–only PCI produced conflicting results regarding the benefits of a multivessel PCI strategy. MethodsA comprehensive search for published randomized controlled trials comparing multivessel PCI with culprit vessel–only PCI was conducted on ClinicalTrials.gov, PubMed, Web of Science, EBSCO Services, the Cochrane Central Register of Controlled Trials, Google Scholar, and scientific conference sessions from inception to September 15, 2019. A meta-analysis was performed using a random-effects model to calculate the risk ratio (RR) and 95% confidence interval (CI). Primary efficacy outcomes were all-cause mortality and reinfarction. ResultsTen randomized controlled trials were included, representing 7,030 patients: 3,426 underwent multivessel PCI and 3,604 received culprit vessel–only PCI. Compared with culprit vessel–only PCI, multivessel PCI was associated with no significant difference in all-cause mortality (RR: 0.85; 95% CI: 0.68 to 1.05) and lower risk for reinfarction (RR: 0.69; 95% CI: 0.50 to 0.95), cardiovascular mortality (RR: 0.71; 95% CI: 0.50 to 1.00), and repeat revascularization (RR: 0.34; 95% CI: 0.25 to 0.44). Major bleeding (RR: 0.92; 95% CI: 0.50 to 1.67), stroke (RR: 1.15; 95% CI: 0.65 to 2.01), and contrast-induced nephropathy (RR: 1.25; 95% CI: 0.80 to 1.95) were not significantly different between the 2 groups. ConclusionsMultivessel PCI was associated with a lower risk for reinfarction, without any difference in all-cause mortality, compared with culprit vessel–only PCI in patients with ST-segment elevation myocardial infarction.

Prognostic importance of culprit lesion location in cardiogenic shock due to myocardial infarction.

As existing results are diverging, and the patient population has changed significantly, this study sought to investigate the prognostic importance of the culprit lesion location in patients with cardiogenic shock due to myocardial infarction (AMICS), in a contemporary and unselected patient population. From the recruitment area of two tertiary heart centres in Denmark, covering 3.9 million citizens corresponding to two-thirds of the Danish population, all AMICS patients in the period of 2010-2017 were individually identified and validated through patient records. A total of 1716 patients with AMICS were identified. Immediate revascularization was performed in 1482 patients (86%). Among these, a culprit lesion in the left main coronary artery (LM) was associated with the highest 30-day mortality rate (66%), plogrank<0.0001, which persisted after multivariable adjustment for variables known to be associated with mortality in AMICS, including age, gender, heart rate, lactate, diabetes, stroke and out-of-hospital cardiac arrest, p=0.002. A culprit lesion in the remaining coronary arteries had comparable and lower 30-day mortality (43-48%), plogrank=0.39. Patients with multivessel disease had comparable prognoses irrespective of whether a culprit-only or multivessel percutaneous coronary intervention strategy was used (plogrank=0.80), and whether partial or complete revascularization was achieved (plogrank=0.24). Among AMICS patients undergoing revascularization, a LM culprit lesion was associated with the highest short-term mortality, whereas patients with a culprit lesion in the remaining coronary arteries had comparable and lower mortality rates. Multivessel disease patients had similar prognoses irrespective of percutaneous coronary intervention approach and whether partial or complete revascularization was achieved.

Prognostic Value of SYNTAX Score in Patients With Infarct-Related Cardiogenic Shock: Insights From the CULPRIT-SHOCK Trial

ObjectivesThis study sought to evaluate the prognostic value of the SYNTAX (SYNergy between PCI with TAXUS and Cardiac Surgery) scores in patients undergoing percutaneous coronary intervention (PCI) for multivessel coronary disease with infarct-related cardiogenic shock (CS). BackgroundThe prognostic value of the SYNTAX score in this high-risk setting remains unclear. MethodsThe CULPRIT-SHOCK (Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock) trial was an international, open-label trial, where patients presenting with infarct-related CS and multivessel disease were randomized to a culprit-lesion-only or an immediate multivessel PCI strategy. Baseline SYNTAX score was assessed by a central core laboratory and categorized as low SYNTAX score (SS ≤22), intermediate SYNTAX score (22<SS≤32) and high SYNTAX score (SS>32). Adjudicated endpoints of interest were the 30-day risk of death or renal replacement therapy (RRT) and 1-year death. Associations between baseline SYNTAX score and outcomes were assessed using multivariate logistic regression. ResultsPre-PCI SYNTAX score was available in 624 patients, of whom 263 (42.1%), 207 (33.2%) and 154 (24.7%) presented with low, intermediate and high SYNTAX score, respectively. A stepwise increase in the incidence of adverse events was observed from low to intermediate and high SYNTAX score for the 30-day risk of death or RRT and the 1-year risk of death (p < 0.001, for all). After multiple adjustments, intermediate and high SYNTAX score remained strongly associated with 30-day risk of death or renal replacement therapy and 1-year risk of all-cause death. There was no significant interaction between SYNTAX score and the coronary revascularization strategy for any outcomes. ConclusionsIn patients presenting with multivessel disease and infarct-related CS, the SYNTAX score was strongly associated with 30-day death or RRT and 1-year mortality.

Management of multivessel coronary artery disease in patients with non-ST-elevation myocardial infarction: a complex path to precision medicine.

Recent analyses suggest the incidence of acute coronary syndrome is declining in high- and middle-income countries. Despite this, overall rates of non-ST-elevation myocardial infarction (NSTEMI) continue to rise. Furthermore, NSTEMI is a greater contributor to mortality after hospital discharge than ST-elevation myocardial infarction (STEMI). Patients with NSTEMI are often older, comorbid and have a high likelihood of multivessel coronary artery disease (MVD), which is associated with worse clinical outcomes. Currently, optimal treatment strategies for MVD in NSTEMI are less well established than for STEMI or stable coronary artery disease. Specifically, in relation to percutaneous coronary intervention (PCI) there is a paucity of randomized, prospective data comparing multivessel and culprit lesion-only PCI. Given the heterogeneous pathological basis for NSTEMI with MVD, an approach of complete revascularization may not be appropriate or necessary in all patients. Recognizing this, this review summarizes the limited evidence base for the interventional management of non-culprit disease in NSTEMI by comparing culprit-only and multivessel PCI strategies. We then explore how a personalized, precise approach to investigation, therapy and follow up may be achieved based on patient-, disease- and lesion-specific factors.

1155Prognostic impact of SYNTAX Score in patients with myocardial infarction with multivessel coronary artery disease and cardiogenic shock: insight from the CULPRIT-SHOCK Trial

Abstract Background The majority of patients presenting with myocardial infarction (MI) and cardiogenic shock (CS) have multivessel coronary artery disease. The prognosis impact of the SYNTAX score (SS) in this setting remains unknown. Purpose To evaluate the prognosis value of the SS in this high-risk population undergoing percutaneous coronary intervention (PCI) Methods The CULPRIT-SHOCK trial was an international, open-label trial, where patients presenting with MI and multivessel disease complicated by CS were randomized to a culprit-lesion-only or an immediate multivessel PCI strategy. Pre-PCI SS was assessed by a central core laboratory and patients were categorized as low SS (SS ≤22), intermediate SS (22&lt;SS≤32) and high SS (SS&gt;32). Adjudicated endpoints of interest were the risks of all-cause death or renal replacement therapy at 30 days and all-cause death at 1 year. Associations between SYNTAX score and outcomes were assessed using multivariate logistic regression. Results SS was available in 632 patients, of whom 265 (41.9%), 211 (33.4%) and 156 (24.7%) presented with low, intermediate and high SS, respectively. Patients with higher SS were older, with more frequent peripheral artery disease, less current smoking, lower creatinine clearance, and higher use of catecholamine. A stepwise increase in the incidence of adverse events transitioning from low to intermediate and high SS was observed with the 30-day risk of death or renal replacement therapy as well as the 1-year risk of all-cause death (p for trend &lt;0.001, for all). After multiple adjustment, intermediate and high SS remained strongly associated with 30-day risk of death and renal replacement therapy and 1-year risk of all-cause death (Figure). There was no significant interaction between SYNTAX score and the coronary revascularization strategy for all endpoints. Conclusion In patients presenting with acute MI, multivessel disease and CS, the SYNTAX score was strongly associated to 30-day and 1-year mortality&lt;/ss≤&lt;ss≤32)&gt; Acknowledgement/Funding The CULPRIT-SHOCK trial was Supported by a grant agreement (602202) from the European Union Seventh Framework Program and by the German Heart Research

Meta-Analysis of Culprit-Only Versus Multivessel Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Disease

Recently, several randomized controlled trials (RCT) in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) have compared a strategy of routine multivessel percutaneous coronary intervention (PCI) performed either as a single procedure or as staged procedures to culprit-only PCI. All of these trials have been underpowered for clinical end points. We searched PubMed, Embase, and Cochrane Central Register of Controlled Trials for RCT comparing multivessel PCI with culprit-only PCI in patients with STEMI and MVD. The primary efficacy outcome was the composite rate of death or MI. Other efficacy outcomes included death, MI, and repeat revascularization. Safety outcomes were contrast-associated acute kidney injury, stroke, and major bleeding. Pairwise direct comparison and mixed-treatment comparison network meta-analyses were performed. Eleven trials that enrolled 3,150 patients with a total of 5,296 patient-years of follow-up were included. In direct comparison meta-analysis, single-procedure multivessel PCI was associated with a reduction in the risk of death or MI (rate ratio [RR] = 0.52; 95% confidence interval [CI] 0.37 to 0.73; p <0.001), due to less death (RR = 0.64; 95% CI 0.40 to 1.02; p = 0.06) and MI (RR = 0.42; 95% CI 0.25 to 0.69; p <0.0001) compared with culprit-only PCI. No heterogeneity (I2 = 0) was present between studies. In contrast, staged multivessel PCI did not significantly reduce death or MI compared with culprit-only PCI. Both multivessel PCI strategies reduced the risk of repeat revascularization without significant differences in safety outcomes. Results were consistent in the mixed-treatment comparison meta-analysis. In conclusion, the present meta-analysis suggests that single-procedure multivessel PCI may be the preferred strategy in patients with STEMI and MVD.

Meta-Analysis of the Optimal Percutaneous Revascularization Strategy in Patients With Acute Myocardial Infarction, Cardiogenic Shock, and Multivessel Coronary Artery Disease

The optimal percutaneous coronary intervention (PCI) revascularization strategy in patients with multivessel (MV) coronary artery disease (CAD) who present with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) has not been systematically addressed. Accordingly, we performed a study-level meta-analysis comparing 2 PCI strategies in these patients-infarct-related artery (IRA) only versus MV revascularization. Studies including patients with AMI and MV CAD complicated with CS who received primary PCI were searched from 2000 to 2016. The primary end points were in-hospital/30-day and mid- to long-term (≥6 month) mortality. Fixed and random effects models were used for analysis. Ten studies (9 prospective and 1 retrospective) involving 6,068 patients met our inclusion criteria. IRA-only PCI was the most frequently used revascularization strategy (4,872 patients, 80%), while MV PCI was performed in 1,196 patients (20%). The MV PCI strategy was associated with higher short-term mortality compared with the IRA-only PCI strategy (odds ratio 1.41, 95% confidence interval 1.15 to 1.71, p= 0.008). There was no difference in mid- to long-term mortality between MV PCI and IRA-only strategies (odds ratio 1.02, 95% confidence interval 0.65 to 1.58, p= 0.94). In conclusion, in patients with AMI and MV CAD complicated by CS, the IRA-only PCI strategy seems to be associated with lower short-term, but not mid- to long-term mortality compared with MVPCI. This finding is different from the revascularization strategy recommended by current professional guidelines and suggests the need for dedicated randomized clinical trials.

The optimal strategy of percutaneous coronary intervention for ST-elevation myocardial infarction patients with multivessel disease: an updated meta-analysis of 9 randomized controlled trials.

The optimal strategy of percutaneous coronary intervention (PCI) for patients with ST-elevation myocardial infarction (STEMI) and multivessel disease (MVD) still remains controversial. This study sought to explore the optimal PCI strategy for those patients. Medline, EMBASE and the Cochrane Controlled Trials Registry were searched for relevant studies. We analyzed the comparison of major adverse cardiac events (MACEs) as the primary end point between the preventive PCI strategy and the culprit only PCI strategy (CV-PCI). The further analysis of two subgroups described as the complete multivessel PCI strategy during primary procedure (CMV-PCI) and the staged PCI strategy (S-PCI) was also performed. Nine randomized trials were identified. The risk of MACEs was reduced significantly regarding to preventive PCI strategy (OR=0.41, 95% CI: 0.31-0.53, P<0.001) compared to CV-PCI strategy. There were lower risks of long-term mortality, reinfarction and repeat revascularization in the preventive PCI group compared to the CV-PCI group (OR=0.41, 95% CI: 0.27-0.62, P<0.001; OR=0.54, 95% CI: 0.32-0.91, P=0.021; OR=0.37, 95% CI: 0.26-0.51, P<0.001). Subgroup analysis showed that staged PCI strategy reduced the incidence of long-term mortality versus CMV-PCI strategy. The preventive PCI is associated with the lower risk of MACEs in STEMI patients with MVD compared to the CV-PCI strategy, and the S-PCI strategy seems to be an optimal choice for these patients rather than the CMV-PCI.

Culprit Vessel Only versus Multivessel Percutaneous Coronary Intervention in Patients Presenting with ST-Segment Elevation Myocardial Infarction and Multivessel Disease

BackgroundThe best strategy for ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease (MVD), who underwent primary percutaneous coronary intervention (PCI) in the acute phase, is not well established.ObjectivesOur goal was to conduct a meta-analysis comparing culprit vessel only percutaneous coronary intervention (culprit PCI) with multivessel percutaneous coronary intervention (MV-PCI) for treatment of patients with STEMI and MVD.MethodsPubmed, Elsevier, Embase, and China National Knowledge Infrastructure (CNKI) databases were systematically searched for randomized and nonrandomized studies comparing culprit PCI and MV-PCI strategies during the index procedure. A meta-analysis was performed using Review Manager 5.1 (Cochrane Center, Denmark).ResultsFour randomized and fourteen nonrandomized studies involving 39,390 patients were included. MV-PCI strategy is associated with an increased short-term mortality (OR: 0.50, 95% CI: 0.32 to 0.77, p = 0.002), long-term mortality (OR: 0.52, 95% CI: 0.36 to 0.74, p<0.001), and risk of renal dysfunction (OR: 0.77, 95% CI: 0.61 to 0.97, p = 0.03) compared with culprit PCI strategy, while it reduced the incidence of revascularization (OR: 2.65, 95% CI: 1.80 to 3.90, p<0.001).ConclusionsThis meta-analysis supports current guidelines which indicate that the non-culprit vessel should not be treated during the index procedure.

Culprit Vessel Only Versus Multivessel and Staged Percutaneous Coronary Intervention for Multivessel Disease in Patients Presenting With ST-Segment Elevation Myocardial Infarction: A Pairwise and Network Meta-Analysis

The purposes of this study were to investigate whether, in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD), percutaneous coronary intervention (PCI) should be confined to the culprit or also nonculprit vessels and, when performing PCI for nonculprit vessels, whether it should take place during primary PCI or staged procedures.A significant percentage of STEMI patients have MVD. However, the best PCI strategy for nonculprit vessel lesions is unknown.Pairwise and network meta-analyses were performed on 3 PCI strategies for MVD in STEMI patients: 1) culprit vessel only PCI strategy (culprit PCI), defined as PCI confined to culprit vessel lesions only; 2) multivessel PCI strategy (MV-PCI), defined as PCI of culprit vessel as well as ≥1 nonculprit vessel lesions; and 3) staged PCI strategy (staged PCI), defined as PCI confined to culprit vessel, after which ≥1 nonculprit vessel lesions are treated during staged procedures. Prospective and retrospective studies were included when research subjects were patients with STEMI and MVD undergoing PCI. The primary endpoint was short-term mortality.Four prospective and 14 retrospective studies involving 40,280 patients were included. Pairwise meta-analyses demonstrated that staged PCI was associated with lower short- and long-term mortality as compared with culprit PCI and MV-PCI and that MV-PCI was associated with highest mortality rates at both short- and long-term follow-up. In network analyses, staged PCI was also consistently associated with lower mortality.This meta-analysis supports current guidelines discouraging performance of multivessel primary PCI for STEMI. When significant nonculprit vessel lesions are suitable for PCI, they should only be treated during staged procedures.