NCDR Data Raises Questions About Benefit of Multivessel PCI in STEMI
There may be no benefit from multivessel PCI after one year among older STEMI patients in routine clinical practice, according to a study recently published in Circulation: Cardiovascular Interventions. The study is part of ACC's Research to Practice (R2P) initiative, which identifies impactful cardiovascular research and analyzes its implications for contemporary clinical practice using ACC's NCDR clinical registries.
Eric A. Secemsky, MD, MSc, FACC, et al., used data from ACC’s CathPCI Registry to look at the comparative effectiveness of multivessel PCI after one year in a broad population of Medicare patients and assess how COMPLETE trial results translate in real-world contemporary practice. The researchers linked registry data to Centers for Medicare and Medicaid Services claims data to look at one-year outcomes among patients ages 65 years and older who received primary PCI for STEMI within ≤12 hours of presentation or within ≤24 hours of thrombolysis. The primary outcome was the composite of death, myocardial infarction and revascularization at 45 days through one year after the index PCI.
The study included 56,332 STEMI admissions at 1,102 sites. Among all patients, 37.7% (21,254) received multivessel PCI within, defined as revascularization of nonculprit lesions, ≤45 days after the index STEMI PCI. Complete revascularization was achieved in 74.8% of those undergoing multivessel PCI. In unadjusted analysis, multivessel PCI was associated with a lower cumulative incidence of the primary outcome (13.9% vs. 18.2%; p<0.01). However, there was no association with instrumental variable analysis, a technique used to account for unmeasured confounders (adjusted risk difference, −0.97%; p=0.46). There was no benefit across sensitivity analyses, including among those who underwent complete revascularization of all disease vessels.
The authors conclude that the “clinical benefit of [multivessel] PCI may not extend equally outside of randomized controlled trials to include patients with more extreme ages and more complex decision-making.”
In an accompanying editorial, Andrew M. Goldsweig, MD, MS, FACC, and Vladimir Džavík, MD, FACC, suggest that COMPLETE trial findings “are correct, but they may not apply to all patients with STEMI, in this case the ones older than 65 years.” They add that the findings of Secemsky, et al., expose a gap in the evidence base. “We are thus left with a need for more randomized trials and registries with collection of more granular data relevant to the elderly patient, and in the case of RCTs, concurrent registries of patients not enrolled in the trials, to better understand the generalizability of results generated,” they write.
Keywords: CathPCI Registry, National Cardiovascular Data Registries, Thrombolytic Therapy, Decision Making, Registries, Myocardial Infarction, Medicare, Centers for Medicare and Medicaid Services, U.S., Percutaneous Coronary Intervention, ST Elevation Myocardial Infarction
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