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Complete vs. Culprit-Only Lesion Intervention in ACS Patients
Study Questions:
What are the outcomes of complete revascularization compared with culprit vessel–only intervention in patients undergoing percutaneous coronary intervention (PCI) for non–ST-segment elevation myocardial infarction (NSTEMI)?
Methods:
The investigators conducted an observational cohort study of 37,491 NSTEMI patients treated between 2005 and 2015 at the eight heart attack centers in London. Clinical details were recorded at the time of the procedure into local databases using the British Cardiac Intervention Society (BCIS) PCI data set. A total of 21,857 patients (58.3%) presented with NSTEMI and multivessel disease (MVD). The primary outcome was all-cause mortality at a median follow-up of 4.1 years (interquartile range, 2.2-5.8 years). A propensity score analysis was carried out using a non-parsimonious logistic regression model comparing cardiovascular intervention versus complete revascularization.
Results:
A total of 11,737 (53.7%) patients underwent single-stage complete revascularization during PCI for NSTEMI, rates that significantly increased during the study period (p = 0.006). Those patients undergoing complete revascularization were older and more likely to be male, diabetic, and have renal disease and a history of previous MI/revascularization compared with the culprit-only revascularization group. Although crude, in-hospital major adverse cardiac event rates were similar (5.2% vs. 4.8%; p = 0.462) between the two groups. Kaplan-Meier analysis demonstrated significant differences in mortality rates between the two groups (22.5% complete revascularization vs. 25.9% culprit vessel intervention; p = 0.0005) during the follow-up period. After multivariate Cox analysis (hazard ratio, 0.90; 95% confidence interval, 0.85-0.97) and the use of propensity matching (hazard ratio, 0.89; 95% confidence interval, 0.76-0.98), complete revascularization was associated with reduced mortality.
Conclusions:
The authors concluded that in NSTEMI patients with MVD, despite higher initial (in-hospital) mortality rates, single-stage complete coronary revascularization appears to be superior to culprit vessel–only PCI in terms of long-term mortality rates.
Perspective:
This observational study reports that complete revascularization is associated with reduced long-term mortality compared with culprit-only revascularization despite an initial increased in-hospital mortality seen in the complete revascularization group, likely related to the higher risk and more complex nature of these patients. Given the limitations of the current analysis, a randomized prospective study with hard clinical endpoints is indicated to assess whether complete revascularization in this patient group is indeed beneficial. At this time, decision regarding culprit vessel–only versus multivessel PCI in NSTEMI should be individualized, based on patient and lesion characteristics.
Keywords: Acute Coronary Syndrome, Diabetes Mellitus, Hospital Mortality, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Renal Insufficiency, Secondary Prevention
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