Optimal timing of complete revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease: a pairwise and network meta-analysis
Authors Guo WQ, Li L, Su Q, Sun YH, Wang XT, Dai WR, Li HQ
Received 3 March 2018
Accepted for publication 4 May 2018
Published 24 August 2018 Volume 2018:10 Pages 1037—1051
Checked for plagiarism Yes
Review by Single-blind
Peer reviewer comments 5
Editor who approved publication: Professor Henrik Toft Sørensen
Wen-Qin Guo, Lang Li, Qiang Su, Yu-Han Sun, Xian-Tao Wang, Wei-Ran Dai, Hong-Qing Li
Department of Cardiology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
Introduction: The optimal revascularization strategy for patients with ST-segment elevation myocardial infarction and multivessel disease is unclear. In this study, we performed a meta-analysis to determine the optimal revascularization strategy for treating these patients.
Methods: Searches of PubMed, the Cochrane Library, clinicaltrial.gov, and the reference lists of relevant papers were performed covering the period between the year 2000 and March 20, 2017. A pairwise analysis and a Bayesian network meta-analysis were performed to compare the effectiveness of early complete revascularization (CR) during the index hospitalization, delayed CR, and culprit only revascularization (COR). The primary endpoint was the incidence of major adverse cardiac events (MACE), which were defined as the composite of recurrent myocardial infarction (MI), repeat revascularization, and all-cause mortality. The secondary endpoints were the rates of all-cause mortality, recurrent MI, and repeat revascularization. This study is registered at PROSPERO under registration number CRD42017059980.
Results: Eleven randomized controlled trials including a total of 3,170 patients were identified. A pairwise meta-analysis showed that compared with COR, early CR was associated with significantly decreased risks of MACE (relative risk [RR] 0.47, 95% CI 0.39–0.56), MI (RR 0.55, 95% CI 0.37–0.83), and repeat revascularization (RR 0.35, 95% CI 0.27–0.46) but not of all-cause mortality (RR 0.78, 95% CI 0.52–1.16). These results were confirmed by trial sequential analysis. The network meta-analysis showed that early CR had the highest probability of being the first treatment option during MACE (89.2%), MI (83.3%), and repeat revascularization (80.4%).
Conclusion: Early CR during the index hospitalization was markedly superior to COR with respect to reducing the risk of MACE, as CR significantly decreased the risks of MI and repeat revascularization compared with COR. However, further study is warranted to determine whether CR during the index hospitalization can improve survival in patients with concurrent ST-segment elevation myocardial infarction and multivessel disease. The optimal timing of CR remains inconclusive considering the small number of studies and patients included in the analysis comparing early and delayed CR.
Keywords: ST-segment elevation myocardial infarction, multivessel disease, percutaneous coronary intervention, meta-analysis, trial sequential analysis
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