Staged PCI May Lower Mortality in STEMI Patients With Multivessel Disease

Among patients with multivessel disease experiencing STEMI, those who undergo staged PCI of nonculprit vessels during the index admission have a lower rate of death than those who are treated in the culprit vessel only, according to registry data published online July 28, 2015, ahead of print in the American Journal of Cardiology.

“In the absence of a large definitive randomized controlled trial, the current findings make a strong argument for the safety and efficacy of in-hospital staged PCI in STEMI patients with multivessel disease,” say Michel R. Le May, MD, of the Ottawa Heart Institute (Ottawa, Canada), and colleagues.

The researchers looked at data from the University of Ottawa Heart Institute STEMI registry on 259 patients who had a staged procedure during the index admission and 779 who underwent culprit-only primary PCI between July 2004 and June 2011.

Baseline characteristics were similar between the 2 groups, except that those who underwent staged PCI were younger and more likely to be male. They also were more likely to have triple-vessel disease and to receive glycoprotein IIb/IIIa inhibitors during primary PCI.

At 180 days, the rate of all-cause mortality (primary endpoint) was lower in the staged PCI group, following a pattern of lower mortality seen both during the index admission and at 30 days. Secondary in-hospital outcomes, including stent thrombosis, reinfarction, stroke, and bleeding, did not differ by treatment. Compared with the staged group, the culprit-only group had higher rates of cardiogenic shock and readmission with PCI (table 1).

No instances of reinfarction, cardiogenic shock, or death were presumed to be related to a nonculprit artery. Additionally, in-hospital staged PCI remained associated with improved survival at 180 days compared with culprit-only PCI after multivariable adjustment for baseline differences (P = .02) as well as in a propensity score-matched analysis (P = .04).

Impact of Timing Remains Uncertain

Current American College of Cardiology/American Heart Association STEMI guidelines support revascularization of nonculprit-vessel disease “at a time separate from primary PCI in patients with ongoing symptoms of myocardial ischemia or intermediate-to-high-risk findings on noninvasive testing,” the study authors note.

Despite this, “the decision to revascularize nonculprit vessels is largely based on their anatomical characteristics, rather than an assessment of the physiological significance of these lesions,” Dr. Le May and colleagues add.

They say that practice is supported by results of the recent PRAMI trial. However, unlike the staged approach used in the current study, PRAMI randomized patients to multivessel revascularization at the time of primary PCI. At this point, Dr. Le May and colleagues write, “the totality of the data regarding the efficacy of multivessel revascularization in STEMI patients remains inconclusive, and the effect of timing on the efficacy of multivessel revascularization has yet to be determined.”

The study authors conclude that more studies are needed to determine how best to manage STEMI patients with multivessel disease, saying that “enough clinical equipoise exists such that a definitive staged PCI trial is feasible and needed in the current era.”

Lack of Clarity on Revascularization

In a telephone interview with TCTMD, Sorin J. Brener, MD, of New York Methodist Hospital (Brooklyn, NY), said the paper is unclear about the degree of revascularization among patients in the staged PCI group.

“They state that multivessel PCI was performed but not whether—or how many—patients were completely revascularized,” he said, adding that it would be helpful if the authors had included information on the number of lesions treated, number of stents placed, and residual SYNTAX score.

Also important and missing from the data, Dr. Brener noted, is the percentage of chronic total occlusions since “it has been demonstrated that [such blockages are] a significant prognostic indicator of adverse outcome.”

While the study raises important questions about the best way to treat STEMI patients with multivessel disease, its lack of randomization and missing data points make interpretation difficult, Dr. Brener said.

Source: 
Russo JJ, Wells GA, Chong AY, et al. Safety and efficacy of staged percutaneous coronary intervention during index admission for ST-elevation myocardial infarction with multivessel coronary disease (insights from the University of Ottawa Heart Institute STEMI registry). Am J Cardiol. 2015;Epub ahead of print. 

Disclosures:

• The study was supported by the University of Ottawa Heart Institute STEMI Program. 
• Dr. Le May reports no relevant conflicts of interest. 

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