The Revascularisation Paradox: Statistical Fragility in the 2024 JACC Meta-Analysis
Methodological Critique & Simulation Synthesis
DOI:
https://doi.org/10.66040/f4y05t14Keywords:
STEMI, Complete Revascularisation, PCI, Network Meta-analysisAbstract
The recent JACC network meta-analysis by Reddy et al. concluded that complete revascularisation following MI reduced all-cause mortality by 15% when compared to culprit-only PCI. This finding contradicts the major CULPRIT-SHOCK trial. We propose that this discrepancy reflects important unaddressed heterogeneity: (1) inclusion of NSTEMI populations (FIRE trial) and (2) exclusion of cardiogenic shock. Using a forensic simulation engine (RevascLogic), we show that when heterogeneity is corrected for using Hartung-Knapp-Sidik-Jonkman (HKSJ) variance estimation and competing-risk modelling, the apparent mortality benefit vanishes, indicating a balance between reduced recurrent ischaemia and increased procedural risk.
References
1. Reddy RK, et al. Percutaneous Coronary Revascularization Strategies After Myocardial Infarction. J Am Coll Cardiol. 2024;84(3):245-257.
2. Thiele H, et al. (CULPRIT-SHOCK). PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock. N Engl J Med. 2017;377:2419-2432.
3. Biscaglia S, et al. (FIRE). Complete or Culprit-Only PCI in Older Patients with Myocardial Infarction. N Engl J Med. 2023;389:889-898.
4. IntHout J, Ioannidis JP, Borm GF. The Hartung-Knapp-Sidik-Jonkman method for random effects meta-analysis. BMC Med Res Methodol. 2014;14:25.
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Copyright (c) 2025 Tia Mistry, Mahmood Ahmad, Igor Buslowski
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