An Observational Study Assessing Immediate Complete Versus Delayed Complete Revascularisation in Patients with
Krishnaraj Sinhji Rathod1,2, Marco Spagnolo1, Mark K Elliott1
1Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK.
Insights
Timing of PCI for multi-vessel disease after STEMI did not impact outcomes. Early outpatient procedures are safe and may reduce hospital stays for patients with ST-segment elevation myocardial infarction (STEMI).
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Outcomes Research
Background:
- Over half of ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) have multi-vessel coronary artery disease (CAD).
- Multi-vessel CAD is linked to poorer prognoses compared to single-vessel disease.
- Optimal timing for revascularization of non-infarct-related arteries (bystander disease) in STEMI patients remains under investigation.
Purpose of the Study:
- To compare clinical outcomes between patients with STEMI and multi-vessel CAD who received complete revascularization as inpatients versus those undergoing staged PCI as early outpatients.
Main Methods:
- Observational cohort study of 1522 patients with STEMI and multi-vessel CAD (2012-2019), excluding those with cardiogenic shock or prior CABG.
- Patients were divided into inpatient complete revascularization or outpatient staged PCI groups.
- Primary outcome was major adverse cardiac events (MACE), including myocardial infarction, target vessel revascularization, and all-cause mortality.
Main Results:
- No significant differences in baseline or procedural characteristics between the inpatient (n=834) and outpatient (n=688) groups.
- Major adverse cardiac events (MACE) rates were similar between groups over follow-up (P = .62), persisting after multivariate adjustment (HR 1.21 [95% CI 0.72-1.96]).
- Propensity-matched analysis also showed no significant difference in outcomes (HR: 0.86 95% CI: 0.75-1.25).
Conclusions:
- The timing of bystander PCI in STEMI patients with multi-vessel CAD does not appear to affect cardiovascular outcomes.
- Early outpatient staged PCI following STEMI is a viable strategy.
- This approach may lead to a significant reduction in hospital length of stay.
Background:
More than half of the patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) have multi-vessel coronary artery disease. This is associated with worse outcomes compared with single vessel disease. Whilst evidence now exists to support complete revascularisation for bystander disease the optimal timing is still debated. This study aimed to compare clinical outcomes in patients with STEMI and multi-vessel disease who underwent complete revascularisation as inpatients in comparison to patients who had staged PCI as early outpatients.
Methods And Results:
We conducted an observational cohort study consisting of 1522 patients who underwent primary PCI with multi-vessel disease from 2012 to 2019. Exclusions included patients with cardiogenic shock and previous CABG. Patients were split into 2 groups depending on whether they had complete revascularisation performed as inpatients or as staged PCI at later outpatient dates. The primary outcome of this study was major adverse cardiac events (consisting of myocardial infarction, target vessel revascularisation and all-cause mortality).834 (54.8%) patients underwent complete inpatient revascularisation and 688 patients (45.2%) had outpatient PCI (median 43 days post discharge). Of the inpatient group, 652 patients (78.2%) underwent complete revascularisation during the index procedure whilst 182 (21.8%) patients underwent inpatient bystander PCI in a second procedure. Overall, there were no significant differences between the groups with regards to their baseline or procedural characteristics. Over the follow-up period there was no significant difference in MACE between the cohorts (P = .62), which persisted after multivariate adjustment (HR 1.21 [95% CI 0.72-1.96]). Furthermore, in propensity-matched analysis there was no significant difference in outcome between the groups (HR: 0.86 95% CI: 0.75-1.25).
Conclusions:
Our study demonstrated that the timing of bystander PCI after STEMI did not appear to have an effect on cardiovascular outcomes. We suggest that patients with multi-vessel disease can potentially be discharged promptly and undergo early outpatient bystander PCI. This could significantly reduce length of stay in hospital.
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