Now or Later: Multi-Vessel versus Culprit-Vessel PCI in patients with NSTEMI or Unstable Angina - A Meta-Analysis of 171,805 Patients.

Background
Among patients with non-ST elevation myocardial infarction (NSTEMI) or unstable angina (UA), it is unclear whether multi-vessel (MVR) percutaneous coronary intervention (PCI) improves clinical outcomes when compared to culprit-only (CVR) intervention.

Methods
A systematic review using PubMed and EMBASE identified 16 studies comparing MVR versus CVR in patients with NSTEMI or UA. Meta-analyses were conducted to estimate the effect size (odds ratio with 95% confidence intervals) using random-effects model at short-term (< 30 days), mid-term (1 year), and long-term (> 2 years) follow-up for the following variables: major adverse cardiovascular events (MACE), myocardial infarction (MI), all-cause death, repeat PCI, coronary artery bypass graft (CABG) surgery, and cerebrovascular accidents (CVA).

Results
A total of 171,805 patients were included (MVR = 58,539 and CVR = 113,266). CVR had lower rates of short-term MACE, MI and CVA and higher rates of CABG compared with MVR. However, MVR was associated with lower rates of mid-term MACE (OR 0.70, 95% CI 0.49-0.98) and all-cause death (OR 0.65, 95% CI 0.51-0.83) with no significant differences in MI, repeat PCI, and CABG. Long-term outcomes were limited by the number of studies, but there were no significant differences between MVR and CVR although a trend was observed towards lower rates of MI and repeat PCI with MVR (Table 1).

Conclusions
While CVR resulted in fewer short-term adverse cardiac events, this was offset by significantly lower rates of MACE and mortality with MVR at one-year. A strategy of multi-vessel PCI for NSTEMI and UA can be safely considered and may be advantageous for patient outcomes.