Abstract 17841: Study Type Determines Outcomes After Multivessel or Culprit-Vessel Intervention for ST-Elevation Myocardial Infarction in Patients with Multivessel Coronary Artery Disease
Introduction: The optimal way to use percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD) remains uncertain. Randomized controlled trials (RCTs), which are restrictive and rigorous, support the use of multivessel PCI; but cohort studies, which are reflective of actual practice and susceptible to bias, support the use of culprit-vessel PCI.
Hypothesis: A cross-design meta-analysis may allow inferences to be made about the parameter θ, which is conditional on both study design and observed mortality differences within and between trials and reflects the underlying hypothesis that the multivessel PCI strategy is superior to culprit-vessel strategy in patients with STEMI and multvessel CAD.
Methods: We used Bayesian hierarchical and cross-design methodologies for statistical inference of 15 clinical trials (4 RCTs, 4 matched cohort studies and 7 other cohort studies) that compared multivessel and culprit-vessel strategies in 36,946 patients with STEMI and multivessel CAD.
Results: The odds ratios (ORs) for mortality rates after the multivessel or culprit-vessel approaches were not different among RCTs (OR 0.75, 95% Bayesian credible interval [BCI] 0.28-1.56), matched cohort studies (OR 1.43, 95% BCI 0.72-2.42), other types of cohort studies (OR 1.64, 95% BCI 0.80-2.85), or in the global summary (OR 1.40, 95% BCI 0.90-1.98). (Figure: Probabality densities normalized to 1 for RCTs, cohort studies, and the global summary from a Bayesian hierarchical and cross-design meta-analyses.)
Conclusions: Neither the multivessel nor the culprit-vessel approach emerges as a preferred strategy in an analysis that accounts for study type and observed mortality differences. Bayesian approaches contextualize the comparison of different strategies suggest that the choice multivessel and culprit-vessel PCI in patients with STEMI and multivessel CAD should be individualized.
- Myocardial infarction, STEMI
- Acute coronary syndromes
- Coronary artery disease
- Percutaneous coronary intervention (PCI)
Author Disclosures: J.A. Bittl: None. C.D. Lang: None.
- © 2014 by American Heart Association, Inc.