Culprit lesion only Revascularization to Multivessel Revascularization in Acute Myocardial Infarction and Cardiogenic Shock: An Updated Meta-Analysis

Background
Optimal revascularization strategy of non-culprit artery in patient with multi-vessel disease presenting with acute myocardial infarction (AMI) complicated by cardiogenic shock remains unknown. We sought to perform a meta-analysis of studies comparing culprit artery-only percutaneous coronary intervention (CO-PCI) to multi-vessel PCI (MV-PCI) in this population.

Methods
PubMed, MEDLINE and EMBASE databases were searched for studies comparing CO-PCI versus MV-PCI in patients with STEMI and cardiogenic shock. Mortality and re-infarction were analyzed at short-term (in-hospital or 30 days) and long-term (>6 months) follow up. Stroke, major bleeding, renal failure, revascularization and intra-aortic balloon pump (IABP) use were measured at short-term follow up. Mantel-Haenszel random effects model was used to calculate odds ratio (OR) and 95% confidence intervals (CI).

Results
Our analysis included 1 randomized controlled trial (RCT) and 11 observational studies. There was no significant difference between CO-PCI versus MV-PCI cohort in terms of short term mortality (OR 0.85,p=0.19), long term mortality (OR 1.07,p=0.73), short term re-infarction (OR 1.04,p=0.92), long term re-infarction (OR 0.91,p=0.83), stroke (OR 0.77,p=0.31), revascularization (OR1.1,p=0.9), IABP use (OR 0.85,p=0.1)and major bleeding (OR 0.85,p=0.13). There was a significant decrease in renal failure in CO-PCI arm (OR 0.74,p=0.03).

Conclusions
MV-PCI does not confer any benefit over CO-PCI in patients with STEMI presenting with cardiogenic shock. Large RCTs are needed to evaluate the optimal revascularization strategy in this setting.