Pathfinding to an optimal strategy of revascularization in primary coronary intervention in patients with multivessel disease: a network meta-analysis of randomized trials

Abstract

Objectives: In ST-segment elevation myocardial infarction (STEMI), current guidelines discourage treatment of the non-culprit lesions at the time of the primary intervention. Latest trials have challenged this strategy suggesting benefit of early complete revascularization. We performed a Bayesian multiple treatment network meta-analysis of randomized clinical trials (RCTs) in STEMI on culprit-only intervention (CO) versus different timing multivessel revascularization, including immediate (IM), same hospitalization (SH) or later staged (ST).

Methods: Outcome parameters were pooled with a random-effects model. For multiple-treatment meta-analysis, a Bayesian Markov chain Monte Carlo method was used.

Results: Eight RCTs involving 2077 patients were identified. ST and IM revascularization was associated with a decrease in major adverse cardiac events (MACEs) compared to culprit-only approach (risk ratio [RR]: 0.43 credible interval [CrI]: 0.22–0.77 and RR: 0.36 CrI: 0.24–0.54, respectively). IM was superior to SH (RR: 0.49 CrI: 0.29–0.80). With regards to myocardial infarction IM was superior to SH (RR: 0.18 CrI: 0.02–0.99). The posterior probability of being the best choice of treatment regarding the frequency of MACEs was 71.2% for IM, 28.5% for ST, 0.3% for SH and 0.05% for culprit-only approach.

Conclusions: Results from RCTs indicate that immediate or staged revascularization of non-culprit lesions reduces major adverse events in patients after primary percutaneous coronary intervention. Differences in MACEs suggest superiority of the immediate or staged intervention; however, further randomized trials are needed to determine the optimal timing of revascularization of the non-culprit lesions.

Keywords:

• Culprit
• meta-analysis
• multivessel
• outcomes
• primary percutaneous intervention
• ST-segment elevation myocardial infarction

Transparency

Declaration of funding

This study was not funded.

Declaration of financial/other relationships

The Authors and CMRO Peer reviewers on this manuscript have no relevant financial or other relationships to disclose companies related to this study or article. CMRO peer reviewers on this manuscript have no relevant financial or other relationships to disclose.