What is the optimal approach to a non- culprit stenosis after ST-elevation myocardial infarction - Conservative therapy or upfront revascularization? An updated meta-analysis of randomized trials

Background Non-culprit percutaneous coronary intervention (PCI) during a ST-segment elevation myocardial infarction (STEMI) remains controversial. We performed a meta-analysis of the published literature comparing a strategy of complete revascularization (CR) with culprit or target vessel revascularization (TVR)-only after STEMI in patients with multi-vessel disease. Methods We searched PubMed/Medline, Cochrane, EMBASE, Web of Science, CINAHL, Scopus and Google-scholar databases from inception to March-2016 for clinical trials comparing CR with TVR during PCI for STEMI. Mantel-Haenszel risk ratio (MH-RR) with 95% confidence intervals (CI) for individual outcomes was calculated using random-effects model. Results A total of 7 randomized trials with 2004 patients were included in the final analysis. Mean follow-up was 25.4 months. Major adverse cardiac events (MACE) (MH-RR: 0.58, 95% CI: 0.43-0.78, P < 0.001), cardiac deaths (MH-RR: 0.42, 95% CI: 0.24-0.74, P = 0.003) and repeat revascularization (MH-RR: 0.36, 95% CI: 0.27-0.48, P < 0.001) were much lower in the CR group when compared to TVR. However, there was no significant difference in the risk of all-cause mortality (0.84, 95% CI: 0.57-1.25, P = 0.394) or recurrent MI (MH-RR: 0.66, 95% CI: 0.34-1.26, P = 0.205) between the two groups. CR appeared to be safe with no significant increase in adverse events including stroke rates (MH-RR: 2.19, 95% CI: 0.59-8.12, P = 0.241), contrast induced nephropathy (MH-RR: 0.73, 95% CI: 0.34-1.57, P = 0.423) or major bleeding episodes (MH-RR: 0.72, 95% CI: 0.34-1.54, P = 0.399). Conclusions CR strategy in STEMI patients with multivessel coronary artery disease is associated with reduction in MACE, cardiac mortality and need for repeat revascularization but with no decrease in the risk of subsequent MI or all-cause mortality. CR was safe however, with no increase in adverse events including stroke, stent thrombosis or contrast nephropathy when compared to TVR.