Use of Culprit vs Multivessel PCI for STEMI Tracks With Trial Results

Recent randomized controlled trial results supporting complete revascularization in STEMI patients have steadily made their mark on US practice, national data show.

Whereas a culprit-only approach has been preferred over the past decade, more-recent years have seen growing use of the more-complete revascularization strategy supported by subsequent trial results. The proportion of such patients treated with multivessel versus culprit-only PCI bottomed out in the second quarter of 2013 before climbing over the study period, which wrapped up in early 2018. Over that span, complete revascularization was shown to be beneficial in patients with STEMI in the PRAMI, CvLPRIT, DANAMI3-PRIMULTI, and Compare-Acute trials, prompting changes to American and European guidelines that allowed for greater consideration of nonculprit PCI.

Use of multivessel PCI varied widely across hospitals, however, ranging from no cases to 100% of cases (median 37.9%), researchers led by Eric Secemsky, MD (Beth Israel Deaconess Medical Center, Boston, MA), report in a study published online November 4, 2020, ahead of print in JAMA Cardiology.

Secemsky told TCTMD that he and his colleagues were motivated to look back at how patients with STEMI and multivessel disease had been treated over time, and how that coincided with evolving evidence and guideline recommendations, up until the time of the 4,041-patient COMPLETE trial. That study, published in September 2019, showed that multivessel PCI was superior to culprit-only intervention when it came to risks of CV death or MI in STEMI patients, buttressing the findings of the earlier, smaller trials.

In the decade leading up to that, “we saw that there was an initial decline with some negative trials and some guideline changes,” Secemsky said, referring to use of multivessel PCI. “And then clinicians followed the data, and there were small pivotal trials [that led to] increasing use of these strategies.”

Whether and when COMPLETE will further boost the use of multivessel PCI remains to be seen, with Secemsky stressing the importance of guidelines to distill what has been learned from the various trials. Guidelines “help standardize how we care for patients and help us understand both the strengths and weaknesses of these studies,” he said. “A lot of these have been smaller studies and have used less-definitive endpoints, like focusing more on target lesion revascularization than on death and MI.”

Depending on how the COMPLETE results are ultimately worked into guidelines, Secemsky said he expects to see the proportion of patients with multivessel disease who get their nonculprit lesions treated rise above 50% over the next 3 or 4 years. “There’s a big possibility that this can have a major impact on clinical practice,” he predicted.

Ups and Downs

For the study, Secemsky et al looked at data from the CathPCI Registry, part of the National Cardiovascular Data Registry. The analysis included 359,879 patients with STEMI and multivessel disease who were treated at 1,598 centers between the third quarter of 2009 and the first quarter of 2018. Overall, 38.5% of patients underwent multivessel PCI, defined as PCI of at least one nonculprit lesion within 45 days of the index procedure.

Of the patients who underwent multivessel PCI, 30.8% had nonculprit PCI during the index procedure, 31.6% during the index hospitalization, and 37.6% after discharge. Complete revascularization was performed in 76.2% of this group.

Between the start of the study period and the second quarter of 2013, a span that saw observational evidence pointing to harm associated with multivessel PCI and guidelines containing class III recommendations against the practice, use of multivessel PCI declined from 42.7% to 32.7%.

As positive trial results started to come out, that figure climbed, reaching 44% by the end of 2017. Over time, nonculprit procedures were increasingly likely to be performed either during the index procedure or the initial hospitalization as opposed to after discharge.

“Similar to a study examining real-world trends in use of aspiration thrombectomy, we found that cardiovascular guidelines lagged behind clinician behavior,” Secemsky et al write in their paper. “While it is reassuring that clinicians respond to new data, this rapid change in practice may lead to harm if there is no consensus that these data are sufficient to promote widespread adoption. In addition, the observed variation in use of multivessel PCI across US institutions suggests that operators interpret and respond to evidence differently.

“Timely guideline changes,” they continue, “are critical to help standardize operator practices assure that the highest quality of care is being delivered uniformly.”

Making Sense of the Evidence

In an accompanying commentary, John Bittl, MD (AdventHealth Ocala, FL), reflects on how the evidence around multivessel PCI in STEMI has evolved—with initial observational data suggesting harm and subsequent trial data showing benefit. “Is there a better example in medical history of how RCTs and observational studies have generated such diametrically opposed recommendations?” he asks. He notes that about two dozen meta-analyses looking at the impact on mortality have provided conflicting results.

“In the medical literature, the evidence for or against multivessel PCI during STEMI has become so tortuous that no two meta-analyses are in complete agreement,” Bittl says.

As for the response of the interventional community to emerging evidence shown in this study, Bittl describes it as “modest at best.”

“The absolute difference of 11 percentage points between the nadir and the peak means that the use of multivessel PCI changed in only one of nine patients. This is not exactly high uptake, which probably reflects the belief throughout all periods that culprit-only PCI is the default strategy, with preemptive PCI on nonculprit vessels being reserved for special circumstances,” he says.

The rapid evolution of the evidence and sometimes contradictory guideline recommendations probably hasn’t helped adoption of multivessel PCI. “Clinicians have been forced to wade through a morass of conflicting reports and a slew of contradictory guidelines that have gone around in circles and still not reached a consensus about the timing of multivessel PCI or provided a consistent recommendation for patients with or without cardiogenic shock,” Bittl writes.

“As with old English equity law, the clinical investigation of multivessel PCI has thrived on contradictory findings that produce little change in practice and, despite all good intentions, has only benefited the experts who need to keep publishing,” he continues. “Secemsky and colleagues should be commended for showing that culprit-only PCI is the preferred approach in practice and routine multivessel PCI is unpropitious.”

Secemsky said, however, that that will likely change now after COMPLETE. “It’s made me consider more often patients who have nonculprit lesions with severe disease, and I’ve definitely taken opportunities to treat those patients either during the hospitalization or within 45 days, understanding that we might be providing some benefit as shown in COMPLETE,” he said. “I don’t think it obligates us, necessarily, to treat all patients with complete revascularization, because there are often underrepresented anatomies and patient populations that are not in these trials.”