Benefits of complete versus target-only revascularization examined in multivessel CAD
medwireNews: Results of a meta-analysis suggest that complete revascularization is associated with a reduced risk for cardiac events, but not overall mortality, among patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD).
The researchers analyzed data from 10 trials comparing any combination of four procedures: complete revascularization at the time of primary percutaneous coronary intervention (PCI), complete revascularization as a staged procedure during hospitalization or after discharge, and culprit-only revascularization.
In a pairwise meta-analysis, they found that the composite endpoint of major adverse cardiac events (MACE) occurred in 14.6% of 1115 patients undergoing complete revascularization, compared with 24.4% of 989 undergoing culprit-only revascularization, a significant difference.
Network meta-analysis indicated that regardless of whether complete revascularization was carried out at the index procedure, as a staged procedure during hospitalization, or after discharge, there was no significant difference in risk between these three strategies.
The reduction in MACE risk was driven by a significantly lower incidence of urgent revascularization among patients undergoing complete versus culprit revascularization, report Islam Elgendy (University of Florida, Gainesville, USA) and colleagues.
In the seven studies reporting urgent revascularization rates, this outcome occurred in 9.0% of 1009 patients in the complete revascularization group versus 18.6% of 881 in the culprit-only group.
The rates of all-cause mortality and spontaneous re-infarction did not significantly differ in patients undergoing complete versus culprit-only revascularization, however, with corresponding rates of 4.6% versus 5.8% and 3.1% versus 5.5%.
Although these findings suggest that the risk for these hard outcomes “is not different among the 4 various revascularization strategies,” the team estimated that almost four times the number of patients included in the meta-analysis would be needed to achieve sufficient power to analyze the effect of different revascularization strategies on all-cause mortality.
“These findings support that future trials are required to determine the impact of a complete revascularization strategy on hard outcomes such as all-cause mortality,” they write in JACC: Cardiovascular Interventions.
The authors of an accompanying commentary, Lloyd Klein (Rush Medical College, Chicago, Illinois, USA) and Amir Lotfi (Baystate Medical Center, Springfield, Massachusetts, USA), agree, noting that “[a]ll existing RCTs are underpowered,” and “the most advantageous [revascularization] strategy remains ambiguous.”
They conclude: “An individualized approach on the basis of symptoms and stress tests, as recommended by the guidelines, can still be regarded as the strategy of choice, with the recognition that selected patients are probably better managed with early complete revascularization.”
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