Complete Versus Culprit-Only Lesion Intervention in Patients With Acute Coronary Syndromes
Krishnaraj S Rathod1, Sudheer Koganti1, Ajay K Jain1
1Barts Health NHS Trust, London, United Kingdom.
Insights
Complete revascularization in non-ST-segment elevation myocardial infarction (NSTEMI) patients with multivessel disease (MVD) reduces long-term mortality. This approach appears superior to culprit-only intervention despite higher initial in-hospital rates.
Area of Science:
- Cardiology
- Interventional Cardiology
Background:
- Many patients with non-ST-segment elevation myocardial infarction (NSTEMI) have multivessel disease (MVD).
- The optimal revascularization strategy for NSTEMI patients with MVD remains uncertain.
Purpose of the Study:
- To compare outcomes of complete revascularization versus culprit vessel-only intervention in NSTEMI patients.
- To evaluate the impact of percutaneous coronary intervention (PCI) strategies on long-term mortality.
Main Methods:
- Observational cohort study of 37,491 NSTEMI patients from 2005-2015 in London.
- Analysis of complete revascularization versus culprit vessel-only PCI using British Cardiac Intervention Society (BCIS) PCI dataset.
- Primary outcome: all-cause mortality at a median follow-up of 4.1 years.
Main Results:
- Complete revascularization (53.7%) significantly increased over the study period.
- Complete revascularization patients were older with more comorbidities.
- Complete revascularization was associated with reduced long-term mortality (HR 0.89; 95% CI 0.76-0.98) after propensity matching.
Conclusions:
- Single-stage complete coronary revascularization is superior to culprit-only PCI for NSTEMI patients with MVD regarding long-term mortality.
- Findings support the need for randomized trials to confirm the benefits of complete revascularization.
Background:
A large proportion of patients presenting with non-ST-segment elevation myocardial infarction (NSTEMI) present with multivessel disease (MVD). There is uncertainty in the role of complete coronary revascularization in this group of patients.
Objectives:
The aim of this study was to investigate the outcomes of complete revascularization compared with culprit vessel-only intervention in a large contemporary cohort of patients undergoing percutaneous coronary intervention (PCI) for NSTEMI.
Methods:
The authors undertook an observational cohort study of 37,491 NSTEMI patients treated between 2005 and 2015 at the 8 heart attack centers in London. Clinical details were recorded at the time of the procedure into local databases using the British Cardiac Intervention Society (BCIS) PCI dataset. A total of 21,857 patients (58.3%) presented with NSTEMI and MVD. Primary outcome was all-cause mortality at a median follow-up of 4.1 years (interquartile range: 2.2 to 5.8 years).
Results:
A total of 11,737 (53.7%) patients underwent single-stage complete revascularization during PCI for NSTEMI, rates that significantly increased during the study period (p = 0.006). Those patients undergoing complete revascularization were older and more likely to be male, diabetic, have renal disease and a history of previous myocardial infarction/revascularization compared with the culprit-only revascularization group. Although crude, in-hospital major adverse cardiac event rates were similar (5.2% vs. 4.8%; p = 0.462) between the 2 groups. Kaplan-Meier analysis demonstrated significant differences in mortality rates between the 2 groups (22.5% complete revascularization vs. 25.9% culprit vessel intervention; p = 0.0005) during the follow-up period. After multivariate Cox analysis (hazard ratio: 0.90; 95% confidence interval: 0.85 to 0.97) and the use of propensity matching (hazard ratio: 0.89; 95% confidence interval: 0.76 to 0.98) complete revascularization was associated with reduced mortality.
Conclusions:
In NSTEMI patients with MVD, despite higher initial (in-hospital) mortality rates, single-stage complete coronary revascularization appears to be superior to culprit-only vessel PCI in terms of long-term mortality rates. This supports the need for further randomized study to confirm these findings.
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