Culprit Vessel Versus Multivessel Intervention at the Time of Primary Percutaneous Coronary Intervention in Patients With ST-Segment–Elevation Myocardial Infarction and Multivessel Disease: Real-World Analysis of 3984 Patients in London

Nov 04, 2014
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Authors:
Iqbal MB, Ilsley C, Kabir T, et al., on behalf of the London Heart Attack Centre (HAC) Group Investigators.
Citation:
Circ Cardiovasc Qual Outcomes 2014;Nov 4:[Epub ahead of print].
Summary By:
Hitinder S. Gurm, MBBS, FACC

Study Questions:

What is the impact of culprit only versus multivessel intervention on outcome of patients undergoing primary percutaneous coronary intervention (PCI)?

Methods:

The authors compared culprit only versus multivessel intervention in 3,984 patients with multivessel disease undergoing primary PCI between 2004 and 2011, at all eight tertiary cardiac centers in London. Multivariable-adjusted models were used to determine independent predictors for in-hospital major adverse cardiovascular events (MACE) and all-cause mortality at 1 year. Propensity matching was used to adjust for the nonrandom use of multivessel PCI.

Results:

Multivessel PCI was performed in 555 patients (14%), while the rest underwent treatment of the culprit vessel only. Culprit only PCI patients had lower in-hospital mortality (3.5% vs. 6.1%), reduced in-hospital MACE (4.6% vs. 7.2%; p = 0.010), and lower mortality at 1 year (7.4% vs. 10.1%; p = 0.031). After adjusting for baseline differences, culprit only PCI was an independent predictor for reduced in-hospital MACE (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.32-0.75; p < 0.001) and survival at 1 year (hazard ratio [HR], 0.65; 95% CI, 0.47-0.91; p = 0.011). In the propensity-matched cohort, similar results were noted (in-hospital MACE: OR, 0.49; 95% CI, 0.32-0.76; p = 0.002; and 1-year survival: HR, 0.64; 95% CI, 0.45-0.90; p = 0.010).

Conclusions:

The authors concluded that culprit only PCI is associated with better outcomes among patients undergoing primary PCI for ST-segment elevation myocardial infarction.

Perspective:

PCI on a nonculprit vessel during primary PCI was a Class III guideline recommendation until very recently. More recently, this recommendation has been modified in face of randomized data suggesting that multivessel PCI is not only safe, but may be associated with better outcomes (Wald DS, et al., PRAMI Investigators, N Engl J Med 2013;369:1115-23). The use of multivessel PCI was restricted to a small number of patients in this study, and it is not clear why the operators chose to treat these patients contrary to guidelines. Propensity matching is susceptible to residual confounding, especially when a therapy is used in a very small subset of patients, and it is likely that the observed differences are a reflection of failure to account for the reason multivessel PCI was performed in those select patients.

Keywords: Myocardial Infarction, Hospital Mortality, London, Confidence Intervals, Percutaneous Coronary Intervention


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