Culprit Vessel vs. Multivessel vs. Staged PCI for STEMI

Study Questions:

What is the optimum strategy for treating nonculprit disease in patients with ST-segment elevation myocardial infarction (STEMI)?

Methods:

The investigators compared revascularization strategies (multivessel intervention [MVI], culprit-vessel intervention only [CVI-O], and culprit-vessel followed by staged in-hospital intervention [CVI-S]) in 6,503 patients with STEMI and multivessel disease (MVD) enrolled in the British Columbia Cardiac Registry (2008-2014). They evaluated all-cause mortality and repeat revascularization at 2 years. Cox proportional hazards models were used to provide adjusted hazard ratios (HRs) with 95% confidence intervals (CIs).

Results:

Compared with MVI, CVI-O (HR, 0.78; 95% CI, 0.64-0.97; p = 0.023) and CVI-S (HR, 0.55; 95% CI, 0.36-0.82; p = 0.004) were associated with lower mortality. Comparing CVI-O with CVI-S, CVI-S was associated with lower mortality (HR, 0.65; 95% CI, 0.47-0.91; p = 0.013). Compared with MVI, CVI-O was associated with increased repeat revascularization (HR, 1.25; 95% CI, 1.02-1.54; p = 0.036). Comparing CVI-O versus CVI-S, CVI-S was associated with lower repeat revascularization (HR, 0.64; 95% CI, 0.46-0.90; p = 0.012). CVI was associated with lower mortality in the presence of nonculprit left circumflex artery disease (HR, 0.63; 95% CI, 0.45-0.89; p = 0.011) and right coronary artery disease (HR, 0.66; 95% CI, 0.44-0.99; p = 0.050), but not nonculprit left anterior descending artery (LAD) disease (HR, 0.83; 95% CI, 0.54-1.28; p = 0.399).

Conclusions:

The authors concluded that in patients with STEMI undergoing primary percutaneous coronary intervention (PCI), a strategy of CVI-S appears to be associated with lower mortality and repeat revascularization rates.

Perspective:

This registry study reports that in patients with STEMI undergoing primary PCI, a strategy of CVI-S appears to be associated with lower mortality and repeat revascularization rates. However, multivessel intervention may be beneficial in select patient groups and in the setting of nonculprit LAD disease. The findings of this registry need prospective evaluation in large adequately powered randomized controlled trials to define the optimal strategy for STEMI patients with multivessel disease.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease

Keywords: Acute Coronary Syndrome, Arrhythmias, Cardiac, Heart Failure, Secondary Prevention, Coronary Artery Disease, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention


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