Complete revascularization leads to significant reductions in all-cause mortality, cardiovascular mortality, myocardial infarction (MI) and major adverse cardiovascular events (MACE) compared with culprit revascularization, according to a new study. The meta analysis, which was published in the July 16 issue of the Journal of the American College of Cardiology, finds that, compared to culprit revascularization, complete revascularization led to a 15% reduction in all-cause mortality. The investigation, which was also published Monday online, finds that, compared to culprit revascularization, complete revascularization led to a 25% reduction in cardiovascular mortality. “We believe this [15% reduction] is due to inclusion of additional trials with additional patients and events, increasing statistical power, and significantly improving precision of the point estimates,” said the paper’s authors, led by Rohin K. Reddy MBBS from the National Heart and Lung Institute at Imperial College London in the United Kingdom. “The mechanism of benefit is likely related to the 25% reduction in cardiovascular mortality and 30% reduction in MI, with 44% reduction in spontaneous MI. “Other mechanisms may include reduction in ischemia-driven arrhythmia, improvements in left ventricular function and reductions in clinical heart failure.” Complete vs. culprit revascularization In complete vs. culprit revascularization, in patients with all MI, complete revascularization led to a 15% reduction in all-cause mortality (relative risk [RR]: 0.85; 95% confidence interval [CI]: 0.74-0.99; P=0.04; I2=7.1%) and a 25% reduction in cardiovascular mortality (RR: 0.75; 95% CI: 0.61-0.91; P=0.009; I2=0%). Compared to culprit revascularization, complete revascularization led to a 30% reduction in MI (RR: 0.70; 95% CI: 0.55-0.90; P=0.008; I2=26.2%) and a 44% reduction in spontaneous MI (RR: 0.56; 95% CI: 0.44-0.71; P<0.001; I2 =0%). Complete revascularization led to a 39% reduction in MACE (RR:0.61; 95% CI:0.50-0.74; P< 0.001) when compared to culprit revascularization with the team highlighting the substantial heterogeneity between trials (I2 =68.3%), likely due to varying MACE definitions. “By calculating P scores, we were able to rank different revascularization strategies,” said the authors of the paper. “Immediate complete revascularization ranked highest for all-cause mortality, cardiovascular mortality, MI and MACE. “Immediate complete revascularization should generally be avoided in patients with hemodynamic instability and complexity of nonculprit lesions should be considered.” No safety concerns The researchers also pointed out that the primary meta-analyses did not identify safety concerns with complete revascularization compared with culprit revascularization. “Complete revascularization in MI may be viewed as a therapy which improves clinically meaningful and bias resistant outcomes such as all-cause mortality, likely through reduced rates of MI, repeat revascularization and cardiovascular mortality, without a significant safety trade-off,” they said. Adrian P. Banning, MBBS, MD, from the John Radcliffe Hospital, Oxford University Hospitals in the UK added that at first glance, complete revascularization was the answer for patients with MI. Authoring an accompanying editorial comment, Banning added that recently published additional data also added uncertainty. Banning highlighted the meta-analysis’ attempt to address two unanswered questions: whether the timing of complete revascularization was important and the role of invasive physiology in detecting which coronary stenosis requires treatment. He said unfortunately, the collated data did not answer either of these questions definitively, although there were suggestions that earlier intervention and physiological assessment would be preferable. Unanswered questions Highlighting and interpreting recent data together with the meta-analysis confirmed that the question about which lesion to stent and “how to do it” in patients presenting with MI and multivessel disease was not yet answered, said Banning. He added that for most nonculprit lesions that were not critically stenosed in MI patients, treatment using angiography alone to guide decision-making was probably insufficient. “…additional imaging of the lesion and optimizing the result of stenting is probably the best way to achieving a robust, long-lasting result,” said Banning. “Deciding which non–flow-limiting lesions identified by imaging might also require interventional treatment may become a new additional focus.” He concluded his comment by saying that determining the optimal mode of imaging (invasive vs noninvasive), the timing, and the thresholds for additional interventional therapy was probably going to keep clinical trialists busy in this area for some time to come. Study methods Twenty-four eligible trials randomized 16,371 patients (weighted mean follow-up: 26.4 months). The primary comparison tested complete vs culprit revascularization. Timing and methods of achieving complete revascularization were assessed. The prespecified primary outcome was all-cause mortality. Outcomes were expressed as relative risk (RR) (95% CI). Sources: Reddy RK, Howard JP, Jamil Y, et al. Percutaneous Coronary Revascularization Strategies After Myocardial Infarction: A Systematic Review and Network Meta-Analysis. J Am Coll Cardiol. 2024;84:276–294. Banning AP, Revascularization Strategies in Patients With MI and MVD: Have We Got the Answers? J Am Coll Cardiol. 2024;84:295–297. Image Credit: iushakovsky – stock.adobe.com