Metaanalysis of Multivessel vs Culprit Artery Only Percutaneous Coronary Intervention in ST Elevation Myocardial Infarction

Daniel C. Garcia; Alexandre M. Benjo; Christopher J. White; Rhanderson N. Cardoso; Francisco Y. B. Macedo; Alan H. Schob; Georges E. El-Hayek; Girish N. Nadkarni; Emad F. Aziz; Rajan A. G. Patel

doi:10.31486/toj.18.0033

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Figure 1.
Process of study selection for metaanalysis.
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Figure 2.
All-cause mortality. Multivessel percutaneous coronary intervention (PCI) strategy vs culprit artery only PCI strategy. CI, confidence interval; df, degrees of freedom; M-H, Mantel-Haenszel.
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Figure 3.
Cardiac mortality. Multivessel percutaneous coronary intervention (PCI) strategy vs culprit artery only PCI strategy. CI, confidence interval; df, degrees of freedom; M-H, Mantel-Haenszel.
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Figure 4.
Reinfarction. Multivessel percutaneous coronary intervention (PCI) strategy vs culprit artery only PCI strategy. CI, confidence interval; df, degrees of freedom; M-H, Mantel-Haenszel.
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Figure 5.
Repeat revascularization. Multivessel percutaneous coronary intervention (PCI) strategy vs culprit artery only PCI strategy. CI, confidence interval; df, degrees of freedom; M-H, Mantel-Haenszel.

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Table 1.

Characteristics of the Studies Included in This Metaanalysis

Study	Inclusion Criteria	Exclusion Criteria	Follow-up, months
Di Mario et al,²⁹ 2004	Chest pain <12 hours STEMI per AHA/ACC guidelines Maximum 3 diseased vessels	Cardiogenic shock or need for vasopressors or balloon counterpulsation Left main disease Lesions in previously treated vessels Recent thrombolysis Single-vessel disease Diffuse calcified or severe tortuosity lesion Side branch >2.0 mm requiring a stent	12
Politi et al,³⁰ 2010	Chest pain <12 hours STEMI per AHA/ACC guidelines	Cardiogenic shock Left main disease Previous CABG Valvular disease Unsuccessful procedures	30 ± 17
Wald et al,²⁴ 2013	STEMI per AHA/ACC guidelines Successfully treated artery >50% stenosis in non–infarct-related artery Treatable stenosis by PCI	Cardiogenic shock Left main disease or equivalent Previous CABG Unable to provide consent Chronic total occlusion	23
Gershlick et al,²⁵ 2015	Suspected or proven STEMI Chest pain <12 hours Infarct-related artery plus at least one non–infarct-related epicardial artery >2 mm with at least one lesion >70% diameter stenosis in one plane or >50% in two planes	Any exclusion criteria for primary PCI <18 years of age Clear indication for or contraindication to multivessel primary PCI according to operator judgment Previous Q wave myocardial infarction Previous CABG Cardiogenic shock Ventricular septal defect or moderate/severe mitral regurgitation Chronic kidney disease (creatinine >200 μmol/L or estimated glomerular filtration rate <30 mL/min/1.73m²) Suspected or confirmed thrombosis of a previously stented artery Only significant non–infarct-related artery lesion is a chronic total occlusion	12

Note: AHA/ACC guidelines require at least 1 mm in two or more contiguous limb electrocardiographic leads or 2 mm in precordial leads. Cardiogenic shock is defined as systolic blood pressure <90 mmHg or heart rate >100 bpm. Left main disease is defined as >50% ostial stenosis, unsuccessful procedures, absence of residual stenosis <30%, and/or TIMI flow grade III.
ACC, American College of Cardiology; AHA, American Heart Association; CABG, coronary artery bypass graft; PCI, percutaneous coronary intervention; STEMI, ST elevation myocardial infarction; TIMI, Thrombolysis in Myocardial Infarction.

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Table 2.

Baseline Characteristics of the Patients Included in This Metaanalysis

		Mean Age,	Male Sex,	Diabetes,	Hypertension,	Anterior Infarct,
Study	Procedure	years ± SD	n (%)	n (%)	n (%)	n (%)
Di Mario et al,²⁹ 2004	Multivessel	63.5 ± 12.4	46 (88.5)	21 (40.4)	30 (57.7)	27 (51.9)
	n=52
	Culprit	65.3 ± 7.4	14 (82.4)	2 (11.8)	6 (35.3)	10 (58.8)
	n=17
Politi et al,³⁰ 2010	Multivessel	64.5 ± 11.7	50 (76.9)	9 (13.8)	32 (49.2)	31 (47.7)
	n=65
	Culprit	66.5 ± 13.2	64 (76.2)	20 (23.8)	50 (59.5)	35 (41.7)
	n=84
	Staged multivessel	64.1 ± 11.1	52 (80.0)	12 (18.5)	42 (64.6)	28 (43.1)
	n=65
Wald et al,²⁴ 2013	Multivessel	62 ± 30	177 (75.6)	35 (15.0)	94 (40.2)	67 (28.6)
	n=234
	Culprit	62 ± 28	186 (80.5)	48 (20.8)	93 (40.3)	89 (38.5)
	n=231
Gershlick et al,²⁵ 2015	Multivessel	64.6 ± 11.2	128 (85.3)	19 (12.7)	54 (36.0)	54 (36.0)
	n=150
	Culprit	65.3 ± 11.9	112 (76.7)	20 (13.7)	51 (34.9)	52 (35.6)
	n=146

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Table 3.

Interventional Characteristics in the Studies Included in This Metaanalysis

Study	Drug-Eluting Stent Use	Time for Secondary Procedure, days	Medical Treatment	Follow-up, months
Di Mario et al,²⁹ 2004	None; all heparin-coated Bx Velocity stents (Cordis Corporation, Cardinal Health)	Not specified	Aspirin Clopidogrel or ticlopidine	12
Politi et al,³⁰ 2010	Infarct artery:10 (11.9%) in the culprit artery only group 5 (7.7%) in the multivessel group 6 (9.2%) in the staged multivessel group	42.3 ± 22.8	Aspirin Statin Clopidogrel for 30 days if bare metal stent or 1 year if drug-eluting stent	30 ± 17
Wald et al,²⁴ 2013	Infarct artery:147 (62.8%) in the multivessel group 135 (58.4%) in the culprit artery only group Non–infarct-related artery: 165 (70.5%) in the multivessel group	40	Aspirin Clopidogrel, prasugrel, or ticagrelor Statin Beta blocker Angiotensin-converting enzyme inhibitor	23
Gershlick et al,²⁵ 2015	141 (94.0%) in the multivessel group127 (87.0%) in culprit artery only group	Not specified	Aspirin Clopidogrel, prasugrel, or ticagrel or Statin Beta blocker Angiotensin-converting enzyme inhibitor	12