多支血管病变合并STEMI的即刻与分期完全血运重建：随机试验的荟萃分析。
完整摘要 · 中文译文
背景：对于ST段抬高型心肌梗死（STEMI）合并多支血管病变的患者，推荐进行完全血运重建。非罪犯病变干预的时机——是在首次手术中立即进行还是分期稍后进行——已在随机对照试验（RCT）中进行了研究。 目的：本研究旨在对比较STEMI合并多支血管病变患者立即与分期完全血运重建的随机对照试验进行荟萃分析。 方法：我们进行了一项频率学、配对荟萃分析。研究根据以下纳入标准进行筛选：比较STEMI患者立即与分期非罪犯血管血运重建的多中心随机对照试验；仅使用第二代（或更新一代）药物洗脱支架；随访时间≥1年；并发表在同行评审期刊上。主要关注结局为全因死亡率，次要结局包括心肌梗死（MI）、心源性死亡和非计划血运重建。汇总估计值采用随机效应模型和基于试验水平HR及95% CI的逆方差加权法计算。本研究方案已在PROSPERO注册（CRD420251124207）。 结果：经过系统检索，4项随机试验共纳入2,651例患者。1年时全因死亡风险在立即完全血运重建组更高（HR：1.50；95% CI：1.02-2.21；P = 0.04；预测区间[PI]：0.80-2.81；I² = 0%；τ² = 0）。立即完全血运重建…… 使用方案规定的定义（包括手术相关性心肌梗死）时，降低了再发心肌梗死的风险（HR：0.58；95% CI：0.36-0.94；P = 0.02；PI：0.22-1.54；I² = 0%；τ² = 0.034），但未降低自发性心肌梗死的风险（HR：0.91；95% CI：0.55-1.48；P = 0.90；PI：0.41-2.00；I² = 0%；τ² = 0.00）。心源性死亡和非计划血运重建的风险在两组间相当。 结论：在STEMI合并多支血管病变患者中，与分期完全血运重建相比，即刻完全血运重建可能与1年全因死亡风险增加相关。由于4项试验中死亡人数相对较少以及研究结果的统计学脆弱性，对死亡率治疗效应的解释应持谨慎态度。本分析结果不支持在这些患者中采用即刻完全血运重建策略。
完整摘要 · 英文原文
BACKGROUND: For patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease, complete revascularization is recommended. The timing of nonculprit lesion intervention, either immediately during the index procedure or staged at a later time, has been investigated in randomized controlled trials (RCTs). OBJECTIVES: This study sought to perform a meta-analysis of RCTs comparing immediate vs staged complete revascularization in patients with multivessel disease presenting with STEMI. METHODS: We conducted a frequentist, pairwise meta-analysis. Studies were selected based on the following inclusion criteria: multicenter RCTs comparing immediate vs staged nonculprit revascularization in patients presenting with STEMI; exclusive use of second-generation (or newer) drug-eluting stents; a follow-up duration of ≥1 year; and publication in a peer-reviewed journal. The primary outcome of interest was all-cause mortality, whereas secondary outcomes included myocardial infarction (MI), cardiac death, and unplanned revascularization. Summary estimates were computed using random-effects models with inverse-variance weighting based on trial-level HRs and 95% CIs. The study protocol was registered on PROSPERO (CRD420251124207). RESULTS: After a systematic search, 4 randomized trials comprising 2,651 patients were included in the meta-analysis. The risk of all-cause death at 1-year was higher with immediate complete revascularization (HR: 1.50; 95% CI: 1.02-2.21; P = 0.04; prediction interval [PI]: 0.80-2.81; I2 = 0%; t2 = 0). Immediate complete revascularization reduced the risk of recurrent MI when using the protocol specified definitions which included procedural MI (HR: 0.58; 95% CI: 0.36-0.94; P = 0.02; PI: 0.22-1.54; I2 = 0%; t2 = 0.034) but did not reduce risk of spontaneous MI (HR: 0.91; 95% CI: 0.55-1.48; P = 0.90; PI: 0.41-2.00; I2 = 0%; τ2 = 0.00). The risk of cardiac death and unplanned revascularization was comparable between the treatment groups. CONCLUSIONS: In STEMI and multivessel disease, immediate complete revascularization may be associated with an increased risk of all-cause death at 1-year when compared with staged complete revascularization. The treatment effect on mortality should be interpreted cautiously because of the relatively low number of deaths across the 4 trials and the statistical fragility of the findings. The findings from this analysis do not support an immediate complete revascularization strategy in these patients.