Introduction: Patients with ST-segment elevation myocardial infarction (STEMI) and multi-vessel coronary artery disease (CAD) have worst outcomes; yet the strategy of multi-vessel versus culprit only percutaneous coronary intervention (PCI) remains uncertain.
Hypothesis: To compare the efficacy and safety of multi-vessel versus culprit only PCI in STEMI patients with multi-vessel CAD.
Methods: Electronic database was searched for the RCTs comparing multi-vessel versus culprit only PCI in patients with STEMI. An updated meta-analysis of these RCTs was performed and summary risk ratios (RR) were calculated for seven outcomes.
Results: A total of nine RCTs with 2,989 patients were included. Follow up ranged from 6 months to 3 years. The incidence of major adverse cardiac events (MACE) was significantly lower in complete revascularization group compared to the culprit only PCI (13.2 vs 23%, RR=0.62; 95% confidence interval [CI]:0.53–0.74, P<0.0001). This was predominantly driven by lower repeat revascularization (8.4 vs 18.4%, RR=0.5; 95% CI:0.4–0.6, P<0.0001) and partly by reduction in cardiovascular mortality (1.8 vs 3%, RR=0.59; 95% CI:0.35–0.99; P=0.049), irrespective of the timing of multi-vessel PCI. The number needed to treat in order to prevent one MACE, cardiovascular mortality and repeat revascularization is 14, 80 and 13 respectively. There was no significant difference in all-cause mortality (4 vs 4.5%, RR=0.90; 95% CI:0.6–1.27; P=0.56), non-fatal myocardial infarction (4.7 vs 5.5%, RR=0.87; 95% CI:0.63–1.20; P=0.39), major bleeding (1.8 vs 1.9%, RR=0.95; 95% CI:0.53–1.69; P=0.85) and contrast induced nephropathy (1.5 vs 1.9%, RR=0.75; 95% CI:0.35–1.6; P=0.45) between both treatment strategies.
Conclusions: In STEMI patients with multi-vessel CAD, our meta-analysis shows that complete revascularization (as index or as staged procedure) is safe and is associated with lower MACE (predominantly driven by lower repeat revascularization and partly by lower cardiovascular mortality) compared to culprit only PCI. Result of an ongoing large (3900 patients) randomized COMPLETE trial will be interesting to see if multi-vessel PCI during STEMI is effective in reducing the hard clinical end points of death or myocardial infarction.