Multivessel revascularization trumps culprit-only approach in STEMI

In patients with ST-segment elevation myocardial infarction (STEMI), multivessel revascularization (MVR) is superior to a culprit-only approach, reports a new meta-analysis.

From the online databases of Medline, Embase, and Cochrane, the researches retrieved 28 studies, totaling 26,892 patients. Of these, 18,377 were treated through culprit-only revascularization (COR), while 8,515 underwent MVR. The primary endpoint was incidence of major adverse cardiovascular events (MACEs), defined as a composite of nonfatal MI, nonfatal stroke, and all-cause death.

Pooled analysis revealed that the odds of MACE were more than 30 percent greater in patients treated with COR than in their MVR comparators (odds ratio [OR], 1.36, 95 percent confidence interval [CI], 1.10–1.70; p=0.005).

Similarly, the risk of angina more than doubled in COR patients (OR, 2.28, 95 percent CI, 1.83–2.85 p≤0.0001), who also had nearly twice the need for repeat revascularization (OR, 1.76, 95 percent CI, 1.22–2.54; p=0.002) as the MVR patients.

In contrast, COR and MVR yielded comparable risks of all-cause and cardiovascular mortality, as well as of repeat coronary artery bypass grafting. The odds of MI and stroke, individually, were likewise statistically similar between treatment groups.

Funnel plots found no strong evidence of publication bias, though there were some indications of variations in sampling.

The study has many important limitations, most attributable to the individual studies included. For instance, patient-level data were missing, disallowing additional controls for differential medication use, contrast-indued renal failure, and duration of hospitalization. It was also impossible to completely account for possible unmeasured confounders.