Meta-Analysis Favors Complete Coronary Revascularization in a Single Go

The latest evidence moves the needle closer in favor of one-go complete revascularization for people with acute myocardial infarction (MI) and multivessel coronary artery disease, according to an updated network meta-analysis.

Researchers found that, compared with culprit-only revascularization, reductions in the following outcomes were achieved with single-setting complete and staged complete revascularization as follows:

• Cardiovascular mortality and MI: single-setting OR 0.52 (95% CI 0.41-0.65); staged OR 0.74 (95% CI 0.62-0.88), respectively
• All-cause mortality and MI: single-setting OR 0.52 (95% CI 0.40-0.67); staged OR 0.78 (95% CI 0.67-0.91)
• MI alone: single-setting OR 0.39 (95% CI 0.26-0.57); staged OR 0.73 (95% CI 0.59-0.90)
• Major adverse cardiovascular events (MACE): single-setting OR 0.42 (95% CI 0.32-0.56); staged OR 0.62 (95% CI 0.47-0.82)
• Repeat revascularization: single-setting OR 0.30 (95% CI 0.18-0.47); staged OR 0.46 (95% CI 0.30-0.71)

Furthermore, compared with staged complete revascularization, single-setting complete revascularization cut the following:

• Cardiovascular mortality/MI: OR 0.70, 95% CI 0.55-0.91
• All-cause mortality/MI: OR 0.67, 95% CI 0.52-0.85
• MI alone: OR 0.53, 95% CI 0.36-0.77
• MACE: OR 0.67, 95% CI 0.50-0.91

Sripal Bangalore, MD, MHA, of New York University Grossman School of Medicine in New York City, and colleagues found that single-setting complete revascularization ranked best for all outcomes, followed by staged complete revascularization, then culprit-only revascularization in third place. Their report was published in Circulation: Cardiovascular Interventions.

“While there were no statistically significant differences in cardiovascular mortality and all-cause mortality between the three strategies, in general, the point estimates favored both complete revascularization strategies over culprit-only revascularization,” they reported.

Beyond that, the difference in timing between these two strategies remains uncertain. It is possible that in staged complete revascularization, a risk of spontaneous periprocedural MIs during the waiting period drives excess events observed in the present meta-analysis.

“Ultimately, a large-scale randomized trial is required to determine whether there are differences between single-setting complete revascularization and staged complete revascularization, ideally powered for cardiovascular death or spontaneous MI to exclude ascertainment bias in periprocedural MI assessment with the single-setting approach,” the authors suggested.

Several trials are now underway to test different timing strategies, including STAGED, OPTION-NSTEMI and OPTION-STEMI, and TERMINAL.

Based on the available evidence, American guidelines currently give staged complete revascularization a class I recommendation and single-setting complete revascularization a class IIb. The European guidelines generally endorse complete revascularization during the index percutaneous coronary intervention or within 45 days, a class I recommendation.

No matter the benefits of single-stage complete revascularization, the staged strategy will likely continue to have an important role in clinical practice, suggested Daniel Chamié, MD, PhD, of Yale School of Medicine in New Haven, Connecticut, and Steven Pfau, MD, of VA Connecticut in West Haven, in an accompanying editorial.

“The next frontier is finding which patients will benefit from immediate or staged CR, and importantly, which patients will benefit most from early staged CR, and which patients can safely defer staged CR to the postdischarge period,” the duo wrote.

For the present report, Bangalore and colleagues updated their own 2018 meta-analysis to include newer trials such as BIOVASC, FIRE, and MULTISTARS AMI, which were reported after the last guideline release.

The meta-analysis included 16 randomized trials with a total of 11,876 participants with acute MI. Patients were randomized to single-setting complete (25.7%), staged complete (36.4%), and culprit vessel-only revascularization (37.8%).

Mean age was 66 and 77% were men.

Study results were largely consistent between ST-segment elevation MI and non-ST-segment elevation MI cohorts.

Notably, people with cardiogenic shock and complex coronary lesions had been excluded from the start, given the entry criteria of the pooled trials.

“[T]he decision on the timing of complete revascularization should be individualized in each patient based on their clinical stability (especially the presence of cardiogenic shock), lesion complexity, and on safety issues including the amount of contrast anticipated for complete revascularization (weighed according to the patient’s risk of contrast nephropathy), radiation dose, and the time of day (or night),” Bangalore’s group thus cautioned.

Additionally, study authors acknowledged that individual patient data weren’t available for the meta-analysis.

“The lack of patient-level data prevents the current meta-analysis from providing a time-to-event relationship and responding to fundamental questions,” explained Chamié and Pfau. “[D]id the higher MI risk with staged CR [complete revascularization] derive from the unstabilization of nonculprit lesions during the waiting time to perform the staged procedure? Did it reflect periprocedural MI during the staged PCI? Or did it occur after the completion of staged CR?”

“In case spontaneous MI occurs after staged CR, one should discriminate whether the event is related to the treated lesions (in-stent restenosis or thrombosis) or the development of a new lesion (nontarget lesion revascularization). In this case, we should better identify the appropriate nonculprit lesions and guide treatment with the best techniques for durable long-term outcomes,” the editorialists added.

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