CRD summary

This generally well-conducted review concluded that in patients with ST-segment elevation myocardial infarction and multivessel disease, multivessel revascularisation appeared to be safe compared to culprit artery-only revascularisation. The authors acknowledged that the results may be biased due to poor reporting in the primary studies.

Authors' objectives

To evaluate the efficacy and safety of multivessel (complete) revascularisation compared to revascularisation of the single affected (culprit) artery in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease.

Searching

PubMed, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) were searched without language restrictions from 1966 to May 2010. Search terms were reported. Bibliographies of reviews, meta-analyses and original studies identified by the electronic search were scanned. Conference proceedings of all major national and international cardiovascular societies were searched (no further details).

Study selection

Studies of patients with STEMI and multivessel disease who underwent multivessel revascularisation within the same hospitalisation and that reported early (<30 days) and long-term efficacy and safety outcomes were eligible for inclusion. Studies that evaluated only patients with cardiogenic shock were excluded.

Most studies were conducted in patients with an acute myocardial infarction and excluded patients with cardiogenic shock and left main coronary artery disease. Mean age was 62 years. Approximately 65% of participants were male, 25% had diabetes, 59% were hypertensive, 18% had prior myocardial infarction, 15% had prior percutaneous coronary intervention (PCI) and 6% had coronary artery bypass graft (CABG). Mean left ventricular ejection fraction was approximately 43%.

Two reviewers independently assessed studies for inclusion; disagreements were resolved by consensus.

Assessment of study quality

The quality of randomised studies was assessed for method of randomisation, allocation concealment, blinding, completeness of outcome data, selective outcome reporting and other sources of bias. Non-randomised studies were assessed for completeness of reporting, risk and propensity adjustments and baseline comparability.

Two reviewers independently assessed study quality; disagreements were resolved by consensus.

Data extraction

Data were extracted for long- and short-term outcomes to enable calculation odds ratios (OR) and 95% confidence intervals (CI). Long-term outcomes were death, myocardial infarction, stroke, repeat PCI, CABG, target vessel revascularisation and major adverse cardiovascular events (MACEs). Early outcomes (≤30 days) included these and stent thrombosis, contrast-induced nephropathy and length of hospital stay. Study authors were contacted to clarify data and obtain missing data.

Two reviewers independently extracted data; disagreements were resolved by consensus.

Methods of synthesis

Summary odds ratios and 95% CI were calculated using the Peto method. Heterogeneity was assessed using the I² statistic (I²<25% was considered low heterogeneity and I²>75% was high heterogeneity). Analyses were stratified according to the strategy used during multivessel revascularisation either as a single procedure (1-setting) or in two or more stages (staged PCI). A sensitivity analysis was used to investigate the impact of study quality. Publication bias was evaluated using funnel plots and/or the Begg test and weighted regression Egger test.

Results of the review

Nineteen studies met the inclusion criteria (n=61,764 participants, range 69 to 25,847): 9,690 participants received multivessel revascularisation and 52,074 received CULPRIT. Only two studies were randomised studies (n=218). Sixteen studies were considered high quality. Two studies used propensity score matching. Other results of the quality assessment were not reported. Mean follow-up was two years (range zero to 42 months).

Early outcomes: Compared to single artery revascularisation, multivessel revascularisation significantly decreased MACEs (OR 0.68, 95% CI 0.57 to 0.81, I²=75%), repeat PCI (OR 0.56, 95% CI 0.32 to 0.98, I²=40%) and CABG (OR 0.54, 95% CI 0.40 to 0.73, I²=0%) and significantly increased contrast-induced nephropathy (OR 1.27, 95% CI 1.12 to 1.45, I²=39%). There was no significant difference in mortality, myocardial infarction, stroke and target vessel revascularisation. Mortality after a single procedure was similar to the overall population; complete revascularisation significantly reduced mortality after a staged procedure. Both subgroups had similar results to the overall population for MACEs.

Late outcomes: Compared to single artery revascularisation, multivessel revascularisation significantly decreased MACEs (OR 0.60, 95% CI 0.50 to 0.72, I²=84%), mortality (OR 0.67, 95% CI 0.58 to 0.79, I²=63%), repeat PCI (OR 0.57, 95% CI 0.43 to 0.77, I²=45%) and CABG (OR 0.47, 95% CI 0.32 to 0.68, I²=0%). There was no significant difference in myocardial infarction, stent thrombosis and target vessel revascularisation. There was no significant difference in mortality between treatments in the single-procedure subgroup. After a staged procedure, complete revascularisation reduced mortality significantly. The subgroups had similar results to the overall population for MACEs.

Results for further subgroup analyses and analyses restricted to high-quality studies were reported. No publication bias was observed for any analysis.

Authors' conclusions

In patients with STEMI and multivessel disease, multivessel revascularisation appeared to be safe compared to culprit artery-only revascularisation.

CRD commentary

The review addressed a clear review question supported by relevant inclusion criteria. The search was comprehensive. The authors attempted to reduce publication and language biases. Each stage of the review process was conducted in duplicate, which reduced potential of error and bias. The paper defined 1-setting as "multivessel revascularisation performed during CULPRIT". The meaning of this was unclear and in this abstract we presumed the definition to be multivessel revascularisation performed during a single procedure. Study quality was assessed using appropriate criteria, but the results were not reported and insufficient study details were reported for an assessment of study quality. Only two of the smaller studies were randomised. Sensitivity analyses were conducted in studies that were considered to be high quality. Heterogeneity was moderate to high in most of the analyses and so the reliability and generalisability of the pooled results was uncertain. The authors acknowledged that the results may be bias due to poor reporting in the primary studies.

This was generally a well-conducted review. Despite some limitations of the available evidence, the conclusion and recommendation for further research seem appropriate.

Implications of the review for practice and research

Practice: The authors did not state implications for practice.

Research: The authors stated that the findings supported the need for a large-scale randomised trial to evaluate the efficacy of revascularisation strategies in patients with STEMI and multivessel disease.

Funding

None stated.

Bibliographic details

Bangalore S, Kumar S, Poddar KL, Ramasamy S, Rha SW, Faxon DP. Meta-analysis of multivessel coronary artery revascularization versus culprit-only revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease. American Journal of Cardiology 2011; 107(9): 1300-1310. [PubMed: 21349487]

Original Paper URL

http://www.ajconline.org/article/S0002-9149(11)00129-9/abstract

Indexing Status

Subject indexing assigned by NLM

MeSH

Angioplasty, Balloon, Coronary; Coronary Artery Disease /therapy; Electrocardiography; Female; Humans; Male; Myocardial Infarction /therapy; Treatment Outcome

AccessionNumber

12011002944

Database entry date

05/10/2011

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.