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Multivessel versus culprit vessel percutaneous coronary intervention in ST-elevation myocardial infarction: is more
Milosz Jaguszewski1, Dragana Radovanovic, Brahmajee K Nallamothu
1Department of Cardiology, University Hospital Zurich, Zurich, Switzerland.
Insights
High-risk ST-elevation myocardial infarction (STEMI) patients are more likely to receive multivessel percutaneous coronary intervention (MPCI). However, MPCI is not associated with increased mortality when risk is considered.
Area of Science:
- Cardiology
- Interventional Cardiology
- Public Health
Background:
- ST-elevation myocardial infarction (STEMI) is a critical condition requiring timely intervention.
- Multivessel percutaneous coronary intervention (MPCI) versus single-vessel PCI (SPCI) strategies are debated, especially in high-risk populations.
- Real-world data is crucial for understanding treatment patterns and outcomes in STEMI.
Purpose of the Study:
- To identify predictors of MPCI use in STEMI patients.
- To evaluate the association between MPCI and in-hospital mortality.
- To assess outcomes of MPCI versus SPCI stratified by patient risk in a real-world setting.
Main Methods:
- Analysis of the Swiss AMIS Plus registry (2005-2012) including 12,000 STEMI patients.
- Identification of 4,941 patients with multivessel disease.
- Stratification of patients into high-risk (left main involvement, cardiac arrest, Killip class III/IV) and low-risk groups.
- Logistic regression to analyze MPCI predictors and mortality association.
Main Results:
- MPCI was performed in 22.4% of STEMI patients with multivessel disease.
- High-risk patients showed significantly higher rates of MPCI.
- Overall in-hospital mortality was higher with MPCI (7.3%) vs. SPCI (4.4%).
- However, mortality rates were similar between MPCI and SPCI in both low-risk (2.0% vs. 2.0%) and high-risk (22.2% vs. 21.7%) groups.
Conclusions:
- High-risk STEMI patients are disproportionately selected for MPCI.
- MPCI is not associated with increased in-hospital mortality when STEMI patients are stratified by risk.
- Risk stratification is essential when comparing outcomes of MPCI and SPCI.
Aims:
We examined what type of STEMI patients are more likely to undergo multivessel PCI (MPCI) in a "real-world" setting and whether MPCI leads to worse or better outcomes compared with single-vessel PCI (SPCI) after stratifying patients by risk.
Methods And Results:
Among STEMI patients enrolled in the Swiss AMIS Plus registry between 2005 and 2012 (n=12,000), 4,941 were identified with multivessel disease. We then stratified patients based on MPCI use and their risk. High-risk patients were identified a priori as those with: 1) left main (LM) involvement (lesions, n=263); 2) out-of-hospital cardiac arrest; or 3) Killip class III/IV. Logistic regression models examined for predictors of MPCI use and the association between MPCI and in-hospital mortality. Three thousand eight hundred and thirty-three (77.6%) patients underwent SPCI and 1,108 (22.4%) underwent MPCI. Rates of MPCI were greater among high-risk patients for each of the three categories: 8.6% vs. 5.9% for out-of-hospital cardiac arrest (p<0.01); 12.3% vs. 6.2% for Killip III/IV (p<0.001); and 14.5% vs. 2.7% for LM involvement (p<0.001). Overall, in-hospital mortality after MPCI was higher when compared with SPCI (7.3% vs. 4.4%; p<0.001). However, this result was not present when patients were stratified by risk: in-hospital mortality for MPCI vs. SPCI was 2.0% vs. 2.0% (p=1.00) in low-risk patients and 22.2% vs. 21.7% (p=1.00) in high-risk patients.
Conclusions:
High-risk patients are more likely to undergo MPCI. Furthermore, MPCI does not appear to be associated with higher mortality after stratifying patients based on their risk.
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