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Evidence summaries

Complete Versus Culprit-Only Revascularization in ST-Elevation Myocardial Infarction

Compared with the culprit-only intervention, complete revascularization in people with ST-elevation myocardial infarction and multi-vessel coronary disease may be associated with lower long-term revascularization need, long-term non-fatal myocardial infarction and long-term cardiovascular mortality. Level of evidence: "C"

The quality of evidence is downgraded by study limitations (unclear allocation concealment), and by imprecise results (few outcome events).

Summary

A Cochrane review [Abstract] 1 included 9 studies with a total of 2 633 subjects with ST-elevation myocardial infarction (STEMI) and multi-vessel coronary disease. A complete revascularization was compared with culprit-only revascularization strategy. Six studies performed the intervention on the non-culprit vessels as a staged intervention, and 3 studies performed the intervention of the non-culprit vessels at the same index procedure. Six studies were performed in Europe, 1 in China, and 2 studies did not report where the study was carried out. The majority of participants were men; male percentage per group was between 61% and 89%.

The complete and the culprit-only revascularization strategies did not differ for long-term all-cause mortality. The complete revascularization strategy was associated with a lower proportion of long-term cardiovascular mortality, long-term non-fatal myocardial infarction, and long-term revascularization. There was no diffference in combined adverse events. Trial Sequential Analysis of long-term all-cause mortality, long-term cardiovascular mortality, and long-term non-fatal myocardial infarction showed that more studies are needed to reach more conclusive results on these outcomes, but more studies may not change present results for long-term repeat revascularization.

Complete revascularization compared to culprit-only revascularization

OutcomeRelative effect (95% CI)Risk with culprit onlyRisk with complete revascularizationParticipants (studies)
Long-term all-cause mortality (HASH(0x2f82cc8) 1 year after the intervention)RR 0.80(0.58 to 1.11)63 per 100050 per 1000(37 to 70)2 417(8 studies)
Long-term cardiovascular mortality (HASH(0x2f82cc8) 1 year after the intervention)RR 0.50(0.32 to 0.79)47 per 100023 per 1000(15 to 37)2 229(6 studies)
Long-term myocardial infarction (HASH(0x2f82cc8) 1 year after the intervention)RR 0.62(0.44 to 0.89)70 per 100043 per 1000(31 to 62)2 099(6 studies)
Long-term revascularization (HASH(0x2f82cc8) 1 year after the intervention)RR 0.47(0.39 to 0.57)208 per 100098 per 1000(81 to 118)2 616(9 studies)
Overall adverse events (pooled short and long term)OR 0.84(0.58 to 1.21)29 per 100024 per 1000(17 to 35)4 086(6 studies)

Clinical comments

Note

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References

  • Bravo CA, Hirji SA, Bhatt DL et al. Complete versus culprit-only revascularisation in ST elevation myocardial infarction with multi-vessel disease. Cochrane Database Syst Rev 2017;(5):CD011986. [PubMed]

Primary/Secondary Keywords