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Published on: June 12, 2021
Multivessel Versus Culprit-Vessel Percutaneous Coronary Intervention in Patients With Non-ST-Segment Elevation
Mohamed A Omer1, Emmanouil S Brilakis2, Kevin F Kennedy3
1Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.
Insights
Multivessel percutaneous coronary intervention (PCI) in patients with non-ST-segment elevation myocardial infarction (NSTEMI), multivessel disease (MVD), and cardiogenic shock reduced in-hospital mortality but increased complications. Long-term survival was similar between multivessel PCI and culprit vessel-only PCI groups.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Outcomes Research
Background:
- The clinical benefits of complete revascularization in patients with non-ST-segment elevation myocardial infarction (NSTEMI), multivessel disease (MVD), and cardiogenic shock are not well-established.
- Percutaneous coronary intervention (PCI) is a common treatment for acute coronary syndromes.
Purpose of the Study:
- To compare in-hospital outcomes and long-term mortality between multivessel PCI and culprit vessel-only PCI in patients with NSTEMI, MVD, and cardiogenic shock.
- To evaluate the safety and efficacy of complete revascularization in this high-risk patient population.
Main Methods:
- A retrospective analysis of 25,324 patients from the National Cardiovascular Data Registry CathPCI Registry (July 2009-March 2018).
- 1:1 propensity score matching was used to compare in-hospital outcomes between multivessel PCI and culprit vessel-only PCI groups.
- Long-term mortality was assessed by matching survivors to the Centers for Medicare and Medicaid Services database.
Main Results:
- Multivessel PCI was performed in 38.7% of patients, with an increasing trend over time.
- After matching, multivessel PCI was associated with lower in-hospital mortality (30.9% vs. 34.4%) but higher rates of bleeding and new dialysis requirement.
- Among survivors, long-term all-cause mortality was similar between the two groups (hazard ratio: 0.95; 95% CI: 0.87 to 1.03).
Conclusions:
- Multivessel PCI in patients with NSTEMI, MVD, and cardiogenic shock is associated with reduced in-hospital mortality but increased peri-procedural complications.
- Complete revascularization does not confer additional long-term mortality benefit for patients who survive to discharge.
- The findings suggest a need for careful consideration of risks and benefits when deciding on the extent of revascularization in this patient group.
Objectives:
The aim of this study was to compare in-hospital outcomes and long-term mortality of multivessel versus culprit vessel-only percutaneous coronary intervention (PCI) in patients with non-ST-segment elevation myocardial infarction (NSTEMI), multivessel disease (MVD) and cardiogenic shock.
Background:
The clinical benefits of complete revascularization in patients with NSTEMI, MVD, and cardiogenic shock remain uncertain.
Methods:
Among 25,324 patients included in the National Cardiovascular Data Registry CathPCI Registry from July 2009 to March 2018, the rates of in-hospital procedural outcomes were compared between those undergoing multivessel PCI and those undergoing culprit vessel-only PCI after 1:1 propensity score matching. Among patients aged ≥65 years matched to the Centers for Medicare and Medicaid Services database, long-term mortality was compared using proportional hazards analysis.
Results:
Multivessel PCI was performed in 9,791 patients (38.7%), which increased from 32.2% in 2010 to 44.2% in 2017 (p for trend <0.001). After 1:1 propensity matching (n = 7,864 in each group), those undergoing multivessel PCI had a 3.5% (95% confidence interval [CI]: 2.0% to 5.0%) lower absolute rate of in-hospital mortality (30.9% vs. 34.4%; p < 0.001; odds ratio [OR]: 0.85; 95% CI: 0.80 to 0.91), but a higher risk for bleeding (13.2% vs. 10.8%; p < 0.001; OR: 1.26; 95% CI: 1.15 to 1.40) and new requirement for dialysis (5.7% vs. 4.6%; p = 0.001; OR: 1.26; 95% CI: 1.10 to 1.46). Among those surviving to discharge, all-cause mortality was similar through 7 years (conditional hazard ratio: 0.95; 95% CI: 0.87 to 1.03; p = 0.20).
Conclusions:
Nearly 40% of patients with NSTEMI with MVD and cardiogenic shock underwent multivessel PCI, which was associated with lower in-hospital mortality but greater peri-procedural complications. Among those surviving to discharge, multivessel PCI did not confer additional long-term mortality benefit.
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