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Study flow diagram.
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Figure 1

Study flow diagram.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Trial Sequential Analysis for complete versus culprit‐only revascularisation on long‐term all‐cause mortality. The diversity‐adjusted required information size (DARIS) was calculated based on an expected relative risk reduction (RRR) of 20% from proportion event in control (Pc) group of 6.3% with an alpha of 2% and beta of 10%.
Figuras y tablas -
Figure 4

Trial Sequential Analysis for complete versus culprit‐only revascularisation on long‐term all‐cause mortality. The diversity‐adjusted required information size (DARIS) was calculated based on an expected relative risk reduction (RRR) of 20% from proportion event in control (Pc) group of 6.3% with an alpha of 2% and beta of 10%.

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Trial Sequential Analysis for complete versus culprit‐only revascularisation on long‐term cardiovascular mortality. The diversity‐adjusted required information size (DARIS) was calculated based on an expected relative risk reduction (RRR) of 20% from Pc group of 4.7% with an alpha of 2% and beta of 10%.
Figuras y tablas -
Figure 5

Trial Sequential Analysis for complete versus culprit‐only revascularisation on long‐term cardiovascular mortality. The diversity‐adjusted required information size (DARIS) was calculated based on an expected relative risk reduction (RRR) of 20% from Pc group of 4.7% with an alpha of 2% and beta of 10%.

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Trial Sequential Analysis for complete versus culprit‐only revascularisation on long‐term non‐fatal myocardial infarction. The diversity‐adjusted required information size (DARIS) was calculated based on an expected relative risk reduction (RRR) of 20% from Pc group of 7.0% with an alpha of 2% and beta of 10%.
Figuras y tablas -
Figure 6

Trial Sequential Analysis for complete versus culprit‐only revascularisation on long‐term non‐fatal myocardial infarction. The diversity‐adjusted required information size (DARIS) was calculated based on an expected relative risk reduction (RRR) of 20% from Pc group of 7.0% with an alpha of 2% and beta of 10%.

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Trial Sequential Analysis for complete versus culprit‐only revascularisation on long‐term revascularisation. The diversity‐adjusted required information size (DARIS) was calculated based on an expected relative risk reduction (RRR) of 20% from Pc group of 20.7% with an alpha of 2% and beta of 10%.
Figuras y tablas -
Figure 7

Trial Sequential Analysis for complete versus culprit‐only revascularisation on long‐term revascularisation. The diversity‐adjusted required information size (DARIS) was calculated based on an expected relative risk reduction (RRR) of 20% from Pc group of 20.7% with an alpha of 2% and beta of 10%.

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Comparison 1 Primary outcomes, Outcome 1 Long‐term all‐cause mortality.
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Analysis 1.1

Comparison 1 Primary outcomes, Outcome 1 Long‐term all‐cause mortality.

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Comparison 1 Primary outcomes, Outcome 2 Long‐term cardiovascular mortality.
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Analysis 1.2

Comparison 1 Primary outcomes, Outcome 2 Long‐term cardiovascular mortality.

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Comparison 1 Primary outcomes, Outcome 3 Long‐term non‐fatal myocardial infarction.
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Analysis 1.3

Comparison 1 Primary outcomes, Outcome 3 Long‐term non‐fatal myocardial infarction.

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Comparison 1 Primary outcomes, Outcome 4 Acute kidney injury.
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Analysis 1.4

Comparison 1 Primary outcomes, Outcome 4 Acute kidney injury.

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Comparison 1 Primary outcomes, Outcome 5 Stroke.
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Analysis 1.5

Comparison 1 Primary outcomes, Outcome 5 Stroke.

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Comparison 1 Primary outcomes, Outcome 6 Bleeding.
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Analysis 1.6

Comparison 1 Primary outcomes, Outcome 6 Bleeding.

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Comparison 2 Secondary outcomes, Outcome 1 Short‐term all‐cause mortality.
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Analysis 2.1

Comparison 2 Secondary outcomes, Outcome 1 Short‐term all‐cause mortality.

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Comparison 2 Secondary outcomes, Outcome 2 Short‐term cardiovascular mortality.
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Analysis 2.2

Comparison 2 Secondary outcomes, Outcome 2 Short‐term cardiovascular mortality.

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Comparison 2 Secondary outcomes, Outcome 3 Short‐term non‐fatal myocardial infarction.
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Analysis 2.3

Comparison 2 Secondary outcomes, Outcome 3 Short‐term non‐fatal myocardial infarction.

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Comparison 2 Secondary outcomes, Outcome 4 Revascularisation.
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Analysis 2.4

Comparison 2 Secondary outcomes, Outcome 4 Revascularisation.

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Comparison 2 Secondary outcomes, Outcome 5 Cost ≥ 1 year.
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Analysis 2.5

Comparison 2 Secondary outcomes, Outcome 5 Cost ≥ 1 year.

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Summary of findings for the main comparison. Complete revascularisation compared to culprit‐only revascularisation in ST elevated myocardial infarction with multi‐vessel disease

Complete revascularisation compared to culprit‐only revascularisation in ST elevated myocardial infarction with multi‐vessel disease

Patient or population: people with STEMI and MVD.
Intervention: complete revascularisation.
Comparison: culprit only.

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with culprit only

Risk with complete revascularisation

Long‐term all‐cause mortality (≥ 1 year after the intervention)

Study population

RR 0.80
(0.58 to 1.11)

2417
(8 RCTs)

⊕⊝⊝⊝
Very low 1,2,3,4

PRAMI study terminated early. CvLPRIT and PRAMI concerning for attrition bias. Only CvLPRIT was judged to have low risk for selection bias.

63 per 1000

50 per 1000
(37 to 70)

Long‐term cardiovascular mortality (≥ 1 year after the intervention)

Study population

RR 0.50
(0.32 to 0.79)

2229
(6 RCTs)

⊕⊝⊝⊝
Very low 1,2,3,4

PRAMI study terminated early. CvLPRIT and PRAMI concerning for attrition bias. Only CvLPRIT was judged to have low risk for selection bias.

47 per 1000

23 per 1000
(15 to 37)

Long‐term myocardial infarction (≥ 1 year after the intervention)

Study population

RR 0.62
(0.44 to 0.89)

2099
(6 RCTs)

⊕⊝⊝⊝
Very low 1,2,3,4

PRAMI study terminated early. CvLPRIT and PRAMI concerning for attrition bias. Only CvLPRIT was judged to have low risk for selection bias.

70 per 1000

43 per 1000
(31 to 62)

Overall adverse events (pooled short and long term)

Study population

OR 0.84
(0.58 to 1.21)

4086
(6 RCTs)

⊕⊝⊝⊝
Very low 1,2,3,4

PRAMI study terminated early. CvLPRIT and PRAMI concerning for attrition bias. Only CvLPRIT was judged to have low risk for selection bias. Open label to the operator may affect this outcome.

29 per 1000

24 per 1000
(17 to 35)

Short‐term all‐cause mortality (within the first 30 days after the intervention)

Study population

RR 0.65
(0.18 to 2.37)

696
(2 RCTs)

⊕⊝⊝⊝
Very low 1,2,3,4

HELP‐AMI trial did not describe in detail their methodology to analyse for bias.

15 per 1000

10 per 1000
(3 to 36)

Long‐term revascularisation (≥ 1 year after the intervention)

Study population

RR 0.47
(0.39 to 0.57)

2616
(9 RCTs)

⊕⊝⊝⊝
Very low 1,2,3

PRAMI study terminated early. CvLPRIT and PRAMI concerning for attrition bias. Only CvLPRIT was judged to have low risk for selection bias. Open label to the operator may affect this outcome.

208 per 1000

98 per 1000
(81 to 118)

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; MVD: multi‐vessel disease; RCT: randomised controlled trial; RR: risk ratio; STEMI: ST elevated myocardial infarction.

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

1 Downgraded due to publication (reporting) bias.

2 Downgraded due to study limitations (largely risk of attrition bias and selection bias).

3 Downgraded because of indirectness: black and Hispanic people, as well as women were under‐represented.

4 Downgraded due to imprecision.

Figuras y tablas -
Summary of findings for the main comparison. Complete revascularisation compared to culprit‐only revascularisation in ST elevated myocardial infarction with multi‐vessel disease
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Table 1. Summary of included studies

Study

Dates

Complete revascularisation (staged vs 1 time)

Intervention criteria in non‐culprit vessel

Mean follow‐up (years)

Description multi‐vessel disease

Country

Number of centres

CvLPRIT 2015

May 2011 to May 2013

At index procedure or before discharge. 65% of participants in invasive group had at index procedure.

> 70% diameter stenosis in 1 plane or > 50% in 2 planes.

2.5

Culprit vessel plus ≥ 1 non‐infarct‐related epicardial artery with ≥ 1 lesion deemed angiographically significant (> 70% stenosis in 1 plane or > 50% in 2 planes).

UK

7

Dambrink and Ghani 2010

June 2004 to February 2007.

Staged 7.5 days after P‐PCI.

FFR < 0.75 and in stenosis > 90%, PCI was performed without FFR measurement. PCI was with BMS or DES.

3

≥ 1 significant stenosis (> 50% stenosis in ≥ 1 view) in ≥ 2 major epicardial coronary arteries, or the combination of a side branch and a main epicardial vessel provided that they supplied different territories.

The Netherlands

1

DANAMI‐3‐PRIMULTI 2015

March 2011 to February 2014

Staged 2 days after P‐PCI.

FFR < 0.8 and those > 90% stenotic arteries visually.

2.2

Significant stenosis (> 50% stenosis visually in arteries > 2 mm diameter) in ≥ 1 of the non‐culprit epicardial coronary arteries or their major side branches in addition to the infarct‐related artery.

Denmark

2

Estevez Loureiro 2014

2010 to 2013

Staged.

Complete. Criteria not described in study.

1

NR.

Spain

NR

HELP AMI 2004

NR

Index procedure.

Not described.

1

NR.

Not described

NR

Politi 2009

January 2003 to December 2007

At index procedure or staged mean 56 days after P‐PCI. 50% participants of complete revascularisation had at intervention of the non‐culprit lesions at index procedure.

> 70% diameter stenosis.

2.5

> 70% diameter stenosis of ≥ 2 epicardial coronary arteries or their major branches by visual estimation.

Not described

NR

PRAGUE‐13 2015

September 2008 to December 2014

Staged between 3 and 40 days after P‐PCI.

> 70% stenosis of non‐culprit coronary artery.

3

≥ 1 vessel, beside the culprit vessel, with significant stenosis (> 70% stenosis).

Czech Republic

6

PRAMI 2013

April 2008 to January 2013

At index procedure.

Stenosis ≥ 50%.

2

The presence of stenosis ≥ 50% in ≥ 1 coronary artery other than the culprit vessel.

UK

5

Zhang 2015

January 2009 to June 2012

Staged between 7 and 10 days after P‐PCI.

75% to 90%.

2

Non‐culprit vessel with significant stenosis (75% to 90% stenosis).

China

NR

BMS: bare‐metal stent; DES: drug‐eluting stent; FFR: fractional flow reserve; NR: not reported in the article; PCI: percutaneous coronary intervention; P‐PCI: primary percutaneous coronary intervention.

Figuras y tablas -
Table 1. Summary of included studies
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Table 2. Baseline information

Study

Group

Sample size (n)

Participants (n (%))

Dropouts (n (%))

% Male

Mean age (years)

% HTN

% DM

% HLD

% Prior MI

% Anterior STEMI

CvLPRIT 2015

Complete

150

139 (92.7)

11 (7.3)

85.3

64.6

36

12.7

27.3

4.7

36

Culprit‐only

146

139 (95.2)

8 (5.5)

76.7

65.3

35

13.7

23.3

3.4

35.6

Dambrink and Ghani 2010

Complete

80

71 (88.8)

1 (1.3)

80

62

26.3

6.3

15

6.3

21.3

Culprit‐only

41

41 (100)

1 (2.4)

80.5

61

42.5

5

30

4.9

23.3

DANAMI‐3‐PRIMULTI 2015

Complete

314

294 (93.6)

1 (0.3)

80

64

41.4

9.2

NR

5.4

33.4

Culprit‐only

313

313 (100)

0

81.5

63

46.6

13.4

NR

8.6

35.8

Estevez Loureiro 2014

Complete

100

NR

NR

NR

NR

NR

NR

NR

NR

NR

Culprit‐only

99

NR

NR

NR

NR

NR

NR

NR

NR

NR

HELP AMI 2004

Complete

52

NR

NR

88.5

63.5

36.5

11.5

41.2

NR

52

Culprit‐only

17

NR

NR

82.4

65.3

58.8

41.2

53

NR

59

Politi 2009

Complete

130

NR

NR

78.5

64

57

16.2

NR

NR

45.4

Culprit‐only

84

NR

NR

76.2

66.5

60

23.8

NR

NR

41.7

PRAGUE‐13 2015

Complete

106

NR

NR

NR

NR

NR

NR

NR

NR

NR

Culprit‐only

108

NR

NR

NR

NR

NR

NR

NR

NR

NR

PRAMI 2013

Complete

234

223 (95.3)

10 (4.3)

75.6

62

40.2

15

NR

8.1

28.6

Culprit‐only

231

229 (99)

8 (3.5)

80.5

62

40.3

20.8

NR

7

38.5

Zhang 2015

Complete

215

NR

NR

61

62.3

64.2

36.7

35.3

NR

36.7

Culprit‐only

213

NR

NR

67.1

62

61

35.2

36.6

NR

40

DM: diabetes mellitus; HLD: hyperlipidaemia; HTN: hypertension; MI: myocardial infarction; n: number of participants; NR: not reported in the article; STEMI: ST elevated myocardial infarction.

Figuras y tablas -
Table 2. Baseline information
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Table 3. Procedure details

Study

Group

Symptoms to PCI time (minute)

PCI without stenting (n (%))

DES (n (%))

BMS (n (%))

2‐Vessel disease (n (%))

3‐Vessel disease (n (%))

Received PCI non‐culprit (n (%))

DAPT

DAPT duration

CvLPRIT 2015

Complete

182

NR

141 (94)

NR

119 (79.3)

31 (20.7)

139 (92.7)

Yes

NR

Culprit‐only

159

NR

127 (87)

NR

110 (75.3)

36 (24.7)

0

Dambrink and Ghani 2010

Complete

NR

6 (7.5)

18 (22.5)

56 (70)

60 (75)

20 (25)

48 (60)

Yes

1 month

Culprit‐only

NR

7 (17.1)

7 (7.1)

27 (66)

33 (80.5)

8 (19.5)

0

DANAMI‐3‐PRIMULTI 2015

Complete

NR

12 (3.8)

298 (95)

0

NR

97 (31)

193 (61.5)

Yes

1 year

Culprit‐only

NR

18 (5.8)

290 (92.7)

0

NR

100 (32)

0

Estevez Loureiro 2014

Complete

NR

NR

NR

NR

NR

NR

NR

NR

NR

Culprit‐only

NR

NR

NR

NR

NR

NR

NR

HELP AMI 2004

Complete

210

0

52 (100)

0

36 (69)

16 (30.8)

NR

Yes

1 month

Culprit‐only

236

0

17 (100)

0

9 (53)

8 (47)

NR

Politi 2009

Complete

NR

NR

11 (8.5)

NR

NR

48 (37)

NR

NR

NR

Culprit‐only

NR

NR

10 (12)

NR

NR

21 (25)

NR

PRAGUE‐13 2015

Complete

NR

NR

NR

NR

NR

NR

NR

NR

NR

Culprit‐only

NR

NR

NR

NR

NR

NR

NR

PRAMI 2013

Complete

NR

1 (< 1)

147 (63)

86 (37)

143 (61.1)

91 (39)

223 (95.3)

Yes

1 month

Culprit‐only

NR

0

135 (58)

96 (42)

155 (67.1)

76 (33)

2 (1)

Zhang 2015

Complete

214

0

215 (100)

0

NR

NR

NR

NR

NR

Culprit‐only

227

0

213 (100)

0

NR

NR

NR

BMS: bare‐metal stent; DAPT: dual antiplatelet therapy; DES: drug‐eluting stent; n: number of participants; NR: not reported in the article; PCI: percutaneous coronary intervention.

Figuras y tablas -
Table 3. Procedure details
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Comparison 1. Primary outcomes

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Long‐term all‐cause mortality Show forest plot

8

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Long‐term all‐cause mortality

8

2417

Risk Ratio (M‐H, Fixed, 95% CI)

0.80 [0.58, 1.11]

2 Long‐term cardiovascular mortality Show forest plot

6

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Long‐term cardiovascular mortality

6

2229

Risk Ratio (M‐H, Fixed, 95% CI)

0.50 [0.32, 0.79]

3 Long‐term non‐fatal myocardial infarction Show forest plot

6

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 Long‐term non‐fatal myocardial infarction

6

2099

Risk Ratio (M‐H, Fixed, 95% CI)

0.62 [0.44, 0.89]

4 Acute kidney injury Show forest plot

3

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

4.1 Short‐term acute kidney injury

2

679

Risk Ratio (M‐H, Fixed, 95% CI)

0.50 [0.14, 1.81]

4.2 Long‐term acute kidney injury

1

296

Risk Ratio (M‐H, Fixed, 95% CI)

0.97 [0.14, 6.82]

5 Stroke Show forest plot

3

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

5.1 Short‐term stroke

1

465

Risk Ratio (M‐H, Fixed, 95% CI)

4.94 [0.24, 102.26]

5.2 Long‐term stroke

2

510

Risk Ratio (M‐H, Fixed, 95% CI)

0.45 [0.10, 2.01]

6 Bleeding Show forest plot

4

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

6.1 Short‐term bleeding

3

1213

Risk Ratio (M‐H, Fixed, 95% CI)

1.00 [0.53, 1.86]

6.2 Long‐term bleeding

2

923

Risk Ratio (M‐H, Fixed, 95% CI)

0.79 [0.45, 1.41]
Figuras y tablas -
Comparison 1. Primary outcomes
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Comparison 2. Secondary outcomes

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Short‐term all‐cause mortality Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Short‐term all‐cause mortality

2

696

Risk Ratio (M‐H, Fixed, 95% CI)

0.65 [0.18, 2.37]

2 Short‐term cardiovascular mortality Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Short‐term cardiovascular mortality

1

627

Risk Ratio (M‐H, Fixed, 95% CI)

0.33 [0.03, 3.18]

3 Short‐term non‐fatal myocardial infarction Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 Short‐term non‐fatal myocardial infarction

1

627

Risk Ratio (M‐H, Fixed, 95% CI)

1.74 [0.52, 5.90]

4 Revascularisation Show forest plot

9

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

4.1 Short‐term revascularisation

2

696

Risk Ratio (M‐H, Fixed, 95% CI)

0.53 [0.20, 1.45]

4.2 Long‐term revascularisation

9

2616

Risk Ratio (M‐H, Fixed, 95% CI)

0.47 [0.39, 0.57]

5 Cost ≥ 1 year Show forest plot

1

69

Mean Difference (IV, Fixed, 95% CI)

‐1948.0 [‐9171.85, 5275.85]
Figuras y tablas -
Comparison 2. Secondary outcomes
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