Real-World Study Shows Benefits of Treating Culprit Vessel Only in STEMI

In patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), culprit-only interventions are associated with better survival at 1 year compared with multivessel procedures, according to a large observational analysis published online November 4, 2014, ahead of print in Circulation: Cardiovascular Quality and Outcomes.
 

Methods
Researchers led by M. Bilal Iqbal, MD, of Harefield Hospital (Middlesex, England), looked at 3,984 consecutive STEMI patients with multivessel disease undergoing primary PCI at 8 tertiary cardiac care centers in London from January 4, 2005, to November 18, 2011. All information was collected prospectively from local British Cardiac Intervention Society databases. Most patients (86.1%) were treated with culprit-vessel intervention.

 


Culprit-vessel PCI was associated with lower 30-day and 1-year mortality compared with multivessel intervention. Additionally, patients receiving culprit-only procedures had lower in-hospital MACE (reinfarction, reintervention, cerebrovascular accident [CVA], and mortality), driven by reductions in each individual component except for CVA (table 1).

Table 1. Clinical Outcomes

 

After adjustment for baseline clinical, anatomic, and procedural variables, culprit-vessel PCI independently predicted a lower risk of mortality at 30 days (HR 0.45; 95% CI 0.31-0.64) and 1 year (HR 0.65; 95% CI 0.47-0.91). It was also an independent predictor of lower in-hospital MACE (OR 0.49; 95% CI 0.32-0.75), reinfarction (OR 0.19, 95% CI 0.05-0.74), and mortality (OR 0.41; 95% CI 0.26-0.65) but not reintervention.

The main study findings were confirmed in propensity-matched and inverse probability treatment-weighted analyses.

Straying From Recent Data

“Our findings suggest that leaving stable nonculprit disease at the time of index intervention does not seem to be associated with increased risk of in-hospital recurrent ischemic events,” Dr. Iqbal and colleagues write. “The results of our study indicate that culprit-only revascularization at the time of [primary PCI] is associated with better outcomes and support the current recommended practice guidelines.”

In an email with TCTMD, Dr. Iqbal acknowledged the difference in outcomes between this analysis and those of the recently released PRAMI and CvLPRIT trials. “Although [they showed] a strategy of complete revascularization may be superior, the composite endpoints in these studies included outcomes which may themselves be dictated by treatment strategy—refractory angina and ischemia-driven revascularization,” he said. “In our analyses, the main outcome analyzed was mortality. When specifically looking at mortality in PRAMI and CvLPRIT, no difference was found between the 2 strategies in either study.”

Moreover, he said, this analysis looked specifically at the type of intervention at the time of primary PCI, whereas it was difficult to tell when patients underwent intervention in the randomized trials. “An important question stemming from CvLPRIT is whether complete revascularization at the time of [primary PCI] or prior to hospital discharge is associated with better outcomes,” Dr. Iqbal wrote.

He acknowledged the limitations of an observational analysis, however, and said “the results of our study should be considered as hypothesis generating.”

It’s Not All About the Guidelines

In a telephone interview with TCTMD, Ron Waksman, MD, of MedStar Washington Hospital Center (Washington, DC), said the choice between culprit-vessel-only and multivessel intervention is patient specific. While this analysis was statistically adjusted, “you can’t adjust for everything,” he emphasized. For example, a patient with precardiogenic shock who undergoes complete revascularization might skew the overall results because such a patient typically does worse.

“To change the guidelines you need to have a definitive randomized trial, but I don't think PRAMI or CvLPRIT were definitive,” Dr. Waksman said, noting that the upcoming COMPLETE trial should solve this question for good.

He added that the guidelines “should be more open to allow multivessel PCI in cases [where] the first vessel was an easy one or in patients with cardiogenic shock.”

But, he said, “most people put too much weight on guidelines because they fear that you have to defend everything that you're doing. Yet they start to lose their personalized medicine. An experienced operator should know what to do without the guidelines.”

 


Source:
Iqbal MB, Ilsley C, Kabir T, et al. 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 3,984 patients in London. Circ Cardiovasc Qual Outcomes. 2014;Epub ahead of print.

 

Disclosures:

  • The study was supported by the National Institute for Health Research Cardiovascular Biomedical Research Unit of Royal Brompton and Harefield National Health Service Foundation Trust and Imperial College London.
  •  Drs. Iqbal and Waksman report no relevant conflicts of interest.

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