PMID- 28470696 OWN - NLM STAT- MEDLINE DCOM- 20170803 LR - 20240321 IS - 1469-493X (Electronic) IS - 1361-6137 (Linking) VI - 5 IP - 5 DP - 2017 May 3 TI - Complete versus culprit-only revascularisation in ST elevation myocardial infarction with multi-vessel disease. PG - CD011986 LID - 10.1002/14651858.CD011986.pub2 [doi] LID - CD011986 AB - BACKGROUND: Multi-vessel coronary disease in people with ST elevation myocardial infarction (STEMI) is common and is associated with worse prognosis after STEMI. Based on limited evidence, international guidelines recommend intervention on only the culprit vessel during STEMI. This, in turn, leaves other significantly stenosed coronary arteries for medical therapy or revascularisation based on inducible ischaemia on provocative testing. Newer data suggest that intervention on both the culprit and non-culprit stenotic coronary arteries (complete intervention) may yield better results compared with culprit-only intervention. OBJECTIVES: To assess the effects of early complete revascularisation compared with culprit vessel only intervention strategy in people with STEMI and multi-vessel coronary disease. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, World Health Organization International Clinical Trials Registry Platform Search Portal, and ClinicalTrials.gov. The date of the last search was 4 January 2017. We applied no language restrictions. We handsearched conference proceedings to December 2016, and contacted authors and companies related to the field. SELECTION CRITERIA: We included only randomised controlled trials (RCTs), wherein complete revascularisation strategy was compared with a culprit-only percutaneous coronary intervention (PCI) for the treatment of people with STEMI and multi-vessel coronary disease. DATA COLLECTION AND ANALYSIS: We assessed the methodological quality of each trial using the Cochrane 'Risk of bias' tool. We resolved the disagreements by discussion among review authors. We followed standard methodological approaches recommended by Cochrane. The primary outcomes were long-term (one year or greater after the index intervention) all-cause mortality, long-term cardiovascular mortality, long-term non-fatal myocardial infarction, and adverse events. The secondary outcomes were short-term (within the first 30 days after the index intervention) all-cause mortality, short-term cardiovascular mortality, short-term non-fatal myocardial infarction, revascularisation, health-related quality of life, and cost. We analysed data using fixed-effect models, and expressed results as risk ratios (RR) with 95% confidence intervals (CI). We used GRADE criteria to assess the quality of evidence and we conducted Trial Sequential Analysis (TSA) to control risks of random errors. MAIN RESULTS: We included nine RCTs, that involved 2633 people with STEMI and multi-vessel coronary disease randomly assigned to either a complete (n = 1381) versus culprit-only (n = 1252) revascularisation strategy. The complete and the culprit-only revascularisation strategies did not differ for long-term all-cause mortality (65/1274 (5.1%) in complete group versus 72/1143 (6.3%) in culprit-only group; RR 0.80, 95% CI 0.58 to 1.11; participants = 2417; studies = 8; I(2) = 0%; very low quality evidence). Compared with culprit-only intervention, the complete revascularisation strategy was associated with a lower proportion of long-term cardiovascular mortality (28/1143 (2.4%) in complete group versus 51/1086 (4.7%) in culprit-only group; RR 0.50, 95% CI 0.32 to 0.79; participants = 2229; studies = 6; I(2) = 0%; very low quality evidence) and long-term non-fatal myocardial infarction (47/1095 (4.3%) in complete group versus 70/1004 (7.0%) in culprit-only group; RR 0.62, 95% CI 0.44 to 0.89; participants = 2099; studies = 6; I(2) = 0%; very low quality evidence). The complete and the culprit-only revascularisation strategies did not differ in combined adverse events (51/2096 (2.4%) in complete group versus 57/1990 (2.9%) in culprit-only group; RR 0.84, 95% CI 0.58 to 1.21; participants = 4086; I(2) = 0%; very low quality evidence). Complete revascularisation was associated with lower proportion of long-term revascularisation (145/1374 (10.6%) in complete group versus 258/1242 (20.8%) in culprit-only group; RR 0.47, 95% CI 0.39 to 0.57; participants = 2616; studies = 9; I(2) = 31%; very low quality evidence). TSA of long-term all-cause mortality, long-term cardiovascular mortality, and long-term non-fatal myocardial infarction showed that more RCTs are needed to reach more conclusive results on these outcomes. Regarding long-term repeat revascularisation more RCTs may not change our present result. The quality of the evidence was judged to be very low for all primary and the majority of the secondary outcomes mainly due to risk of bias, imprecision, and indirectness. AUTHORS' CONCLUSIONS: Compared with culprit-only intervention, the complete revascularisation strategy may be superior due to lower proportions of long-term cardiovascular mortality, long-term revascularisation, and long-term non-fatal myocardial infarction, but these findings are based on evidence of very low quality. TSA also supports the need for more RCTs in order to draw stronger conclusions regarding the effects of complete revascularisation on long-term all-cause mortality, long-term cardiovascular mortality, and long-term non-fatal myocardial infarction. FAU - Bravo, Claudio A AU - Bravo CA AD - Montefiore Einstein Center for Heart & Vascular Care, Albert Einstein College of Medicine, Montefiore Medical Center, 111 East 210th Street, Bronx, New York, USA, 10467. FAU - Hirji, Sameer A AU - Hirji SA AD - Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, USA, 02115. FAU - Bhatt, Deepak L AU - Bhatt DL AD - Heart & Vascular Centre, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, USA, 02115. FAU - Kataria, Rachna AU - Kataria R AD - Department of Internal Medicine, Yale New Haven Health System, 267 Grant Street, Bridgeport, Connecticut, USA, 06610. FAU - Faxon, David P AU - Faxon DP AD - Cardiovascular Medicine, Brigham and Women's Hospital, Brigham Circle, 1620, Boston, Massachusetts, USA, 02120-1613. FAU - Ohman, E Magnus AU - Ohman EM AD - Programme for Advanced Coronary Diseases, Division of Cardiovascular Medicine, Duke Heart Center, Ambulatory Care, Box 3126, Room 8676A HAFS Building, Duke University Medical Center, Durham, North Carolina, USA, 27710. FAU - Anderson, Kevin L AU - Anderson KL AD - School of Medicine, Duke University, 201 Trent Drive, Durham, North Carolina, USA, 27705. FAU - Sidi, Akil I AU - Sidi AI AD - Department of Biology, University of North Carolina, 201 Councilman court, Morrisville, North Carolina, USA, 27560. FAU - Sketch, Michael H Jr AU - Sketch MH Jr AD - Department of Medicine/Cardiology, Duke University School of Medicine, DUMC 3157, Durham, North Carolina, USA, 27710. FAU - Zarich, Stuart W AU - Zarich SW AD - Department of Cardiology, Yale New Haven Health System, 267 Grant St, Bridgeport, Connecticut, USA, 06610. FAU - Osho, Asishana A AU - Osho AA AD - General Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA, 02114. FAU - Gluud, Christian AU - Gluud C AD - The Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen, Denmark, DK-2100. FAU - Kelbaek, Henning AU - Kelbaek H AD - Cardiac Catheterization Laboratory, Zealand University, Roskilde Hospital, Kogevej 7-13, Roskilde, Denmark, 4000. FAU - Engstrom, Thomas AU - Engstrom T AD - Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen, Denmark, 2100. FAU - Hofsten, Dan Eik AU - Hofsten DE AD - Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen, Denmark, 2100. FAU - Brennan, James M AU - Brennan JM AD - Department of Medicine/Cardiology, Duke University School of Medicine, DUMC 3157, Durham, North Carolina, USA, 27710. LA - eng PT - Journal Article PT - Meta-Analysis PT - Review PT - Systematic Review DEP - 20170503 PL - England TA - Cochrane Database Syst Rev JT - The Cochrane database of systematic reviews JID - 100909747 SB - IM CIN - Heart. 2018 Jul;104(14):1144-1147. PMID: 29439169 MH - Cause of Death MH - Coronary Stenosis/complications/mortality/*surgery MH - Female MH - Humans MH - Male MH - Myocardial Revascularization/adverse effects/*methods/mortality MH - Randomized Controlled Trials as Topic MH - ST Elevation Myocardial Infarction/etiology/mortality/*surgery PMC - PMC6481381 COIS- CB: none known. SH: none known. DB: Advisory Board: Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, Regado Biosciences; Board of Directors: Boston VA Research Institute, Society of Cardiovascular Patient Care; Chair: American Heart Association Quality Oversight Committee; Data Monitoring Committees: Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, Population Health Research Institute (including for his role on the DSMB of COMPLETE); Honoraria: American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), Harvard Clinical Research Institute (clinical trial steering committee), HMP Communications (Editor in Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), Population Health Research Institute (clinical trial steering committee), Slack Publications (Chief Medical Editor, Cardiology Today's Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (CME steering committees); Other: Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Chair), VA CART Research and Publications Committee (Chair); Research Funding: Amarin, Amgen, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Forest Laboratories, Ischemix, Lilly, Medtronic, Pfizer, Roche, Sanofi Aventis, The Medicines Company; Royalties: Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald's Heart Disease); Site Co-Investigator: Biotronik, Boston Scientific, St. Jude Medical; Trustee: American College of Cardiology; Unfunded Research: FlowCo, PLx Pharma, Takeda. RK: none known. DF: has received compensation for travel expenses related to his membership on the board of the Alliance for a Healthier Generation and the American Heart Association. Dr Faxon has also received compensation for consulting as a member of a Data Safety Monitoring Board from Medtronic, Boston Scientific, and Biotronik. Dr Faxon has received stock options from RIVA Medical as well as honoraria from the American Heart Association for his service as an editor of Circulation. All compensation received is unrelated to this review. EO: has received compensation for consulting from Abiomed, Astra Zeneca, Biotie, Boehringer Ingelheim, Bristol Meyers Squibb, Daiichi Sankyo, Eli Lilly & Company, Faculty Connection, Gilead Sciences, Ikaria, Ivivi, Janssen Pharmaceuticals, LipoScience, Merck, Pozen, Roche, Sanofi Aventis, Stealth Peptides, The Medicines Company, and Web MD. Dr Ohman has received institutional grants for clinical trials from Daiichi Sankyo, Eli Lilly & Company, Gilead Sciences, and Janssen Pharmaceuticals. Dr Ohman has received payment for lectures from Gilead Sciences, Janssen Pharmaceuticals, and LipoScience. All compensation received is unrelated to this review. KA: none known. AS: none known. MS: none known. SZ: has received compensation for lectures from GSK and Arbor Pharmaceuticals for topics unrelated to this review. AO: none known. CG: none known. HK: none known. TE: fees from Boston Scientific, St. Jude Medical, Astra Zeneca, and Bayer. DH: none known. JB: none known. EDAT- 2017/05/05 06:00 MHDA- 2017/08/05 06:00 PMCR- 2018/05/03 CRDT- 2017/05/05 06:00 PHST- 2017/05/05 06:00 [pubmed] PHST- 2017/08/05 06:00 [medline] PHST- 2017/05/05 06:00 [entrez] PHST- 2018/05/03 00:00 [pmc-release] AID - CD011986.pub2 [pii] AID - 10.1002/14651858.CD011986.pub2 [doi] PST - epublish SO - Cochrane Database Syst Rev. 2017 May 3;5(5):CD011986. doi: 10.1002/14651858.CD011986.pub2.