Complete versus culprit-only revascularization for ST-segment-elevation myocardial infarction and multivessel disease: a meta-analysis and trial sequential analysis of randomized trials.

BACKGROUND The 2013 American College of Cardiology Foundation/American Heart Association guidelines for patients with ST-segment-elevation myocardial infarction gives a class III indication for nonculprit artery percutaneous coronary intervention at the time of primary percutaneous coronary intervention, driven by data from observational studies. However, more recent trials suggest otherwise. METHODS AND RESULTS We conducted PUBMED, EMBASE, and CENTRAL searches for randomized trials comparing complete versus culprit-only revascularization in patients with ST-segment-elevation myocardial infarction. Efficacy outcomes were major adverse cardiovascular events, as well as death, cardiovascular death, myocardial infarction, and repeat revascularization. Safety outcomes were contrast-induced nephropathy, contrast volume used, and procedure time. Five trials with 1165 patients fulfilled the inclusion criteria. Complete revascularization (68% during index percutaneous coronary intervention) was associated with significant reduction in major adverse cardiovascular events (rate ratio =0.48; 95% confidence interval =0.37-0.61), death (rate ratio =0.60; 95% confidence interval =0.38-0.97), cardiovascular death (rate ratio =0.38, 95% confidence interval =0.20-0.73), and repeat revascularization (rate ratio =0.42; 95% confidence interval =0.31-0.57) when compared with culprit-only revascularization. However, trial sequential analyses (similar to interim analysis of a randomized trial) powered for a 25% relative reduction showed firm evidence (cumulative z-curve crossed the monitoring boundary) only for major adverse cardiovascular events driven by a decrease in repeat revascularization with no firm evidence for reduction in death and myocardial infarction. Moreover, there was a significant increase in contrast volume use (mean difference 85.12 [70.41-83.00] ml) and procedure time (mean difference 16.42 [13.22-19.63] mins) with complete revascularization without increase in contrast-induced nephropathy. CONCLUSIONS In patients with ST-segment-elevation myocardial infarction, immediate or staged complete revascularization results in significant reduction in major adverse cardiovascular events driven largely by reduction in repeat revascularization with no firm evidence for the reduction in death or myocardial infarction when compared with culprit-only revascularization.