Meta-analysis: Multivessel PCI Comparable to Culprit-Only Approach in STEMI

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A strategy of multivessel percutaneous coronary intervention (PCI) performed at the time of culprit revascularization or during the same hospital stay produces similar outcomes to a culprit-only strategy in patients with ST-segment elevation myocardial infarction (STEMI), according to a large meta-analysis published online February 25, 2011, ahead of print in the American Journal of Cardiology.

Current American College of Cardiology/American Heart Association STEMI guidelines do not recommend PCI of a non-infarct-related artery and are ambiguous regarding the best way to manage remaining multivessel disease. Options include staged revascularization, medical management, and ischemia-driven revascularization strategies.

To evaluate the efficacy and safety of multivessel vs. culprit artery-only PCI, Sripal Bangalore, MD, of the New York University School of Medicine (New York, NY), and colleagues examined 19 studies (23 arms) totaling 61,764 patients with STEMI. Multivessel revascularization had to be performed at the time of culprit artery strategy (1-setting cohort) or during the same hospitalization (staged cohort).

Equivalent Short- and Long-term Outcomes

Of the 19 studies, 2 were randomized trials. Overall, multivessel revascularization was performed in 16% of patients. Baseline characteristics were similar between patients who had multivessel revascularization and those who did not, although multivessel PCI patients were more likely to be men and to present with heart failure and less likely to have diabetes or previous CABG.

For early outcomes (≤ 30 days), multivessel PCI had no impact on MI risk in the overall cohort (OR 1.74; 95% CI 0.94-3.20) or the 1-setting cohort (OR 0.56; 95% CI 0.25-1.27). But in the staged revascularization cohort, the likelihood of MI was increased with multivessel PCI (OR 7.52; 95% CI 2.97-19.02; P for interaction < 0.0001). The choice of revascularization strategy also made no difference in terms of stroke or TVR in the overall cohort, and the interaction by setting (1 setting vs. staged) was negative. There was no difference in the length of hospital stay between the 2 groups (P = 0.37).

Overall, multivessel revascularization was associated with a 44% decrease in the odds of repeat PCI and a 46% decrease in the odds of CABG within 30 days. It also resulted in a 32% decrease in early MACE risk. There was no interaction by setting for any of the 3 endpoints (table 1).

Table 1. Multivessel vs. Culprit-Only PCI: Early Outcomes

For long-term outcomes (2.0 ± 1.1 years follow-up), multivessel PCI decreased the odds of mortality by 33% in the overall cohort and more so with staged revascularization. There was no difference in MI for the overall cohort (OR 1.03; 95% CI 0.81-1.31). But in the multivessel revascularization group, the risk was lower in the 1-setting cohort (OR 0.55; 95% CI 0.34-0.87) and increased in the staged revascularization cohort (OR 1.29; 95% CI 0.98-1.71, P for interaction = 0.002). The choice of revascularization did not affect TVR overall, but multivessel PCI increased TVR risk in the staged cohort.

However, there was a 43% decrease in the odds of repeat PCI and a 53% decrease in the need for CABG with multivessel procedures for the overall cohort, and interaction by setting was negative. Similarly, there was no difference in stent thrombosis for the overall cohort, with no interaction by setting. Multivessel PCI also imparted a 40% decrease in MACE, with no interaction by setting (table 2).

Table 2. Multivessel vs. Culprit-Only PCI: Long-Term Outcomes

 
Time Ripe for Randomized Trial

In an e-mail communication with TCTMD, Dr. Bangalore said although the data are largely from nonrandomized studies with consequent biases, they do show probable safety and efficacy of a multivessel revascularization strategy over guideline-recommended culprit artery revascularization alone.

“The time is ripe for a large-scale randomized trial to specifically address the comparative effectiveness of revascularization strategies in patients with STEMI and multivessel disease, who are at high risk of future cardiovascular events,” he said.

According to Dr. Bangalore, such a trial would address the safety of multivessel revascularization in the STEMI setting. It would also serve as a means to evaluate comparative efficacy of a multivessel vs. culprit-only strategy, which would help make practice patterns more uniform and likely answer the question of who should be revascularized and when.

Questions Remain to Be Answered

In a telephone interview with TCTMD, Jeffrey W. Moses, MD, of Columbia University Medical Center (New York, NY), said the meta-analysis is thought-provoking but by no means definitive.

“We know that registries are fraught with confounders, but having said that, this does open the door on the subject of how to treat multivessel disease and whether treating multivessel disease improves mortality,” he said. “It’s a good start in looking at this issue.”

Dr. Moses agreed with the study authors that a large-scale randomized trial is needed. Currently, he added, there is at least 1 ongoing randomized trial looking at treatment vs. no treatment of chronic total occlusions after infarction that hopefully will be “another step forward in answering the questions about the necessity of complete revascularization in post-infarct patients.”

 

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Source:
Bangalore S, Kumar S, Poddar KL, et al. Meta-analysis of multivessel coronary artery revascularization versus culprit-only revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease. Am J Cardiol. 2011;Epub ahead of print.

 

 

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