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Complete Revascularization vs Culprit Lesion-Only Percutaneous Coronary Intervention for Angina-Related Quality of
Shamir R Mehta1, Jia Wang1, David A Wood2
1Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.
Insights
Complete revascularization in STEMI patients with multivessel CAD slightly improved angina-free status compared to culprit lesion-only PCI. This offers an additional health status benefit beyond reduced cardiovascular events.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Patient-Reported Outcomes
Background:
- Multivessel coronary artery disease (CAD) with ST-segment elevation myocardial infarction (STEMI) often requires intervention.
- Complete revascularization reduces major cardiovascular events versus culprit lesion-only percutaneous coronary intervention (PCI).
- The impact of complete revascularization on angina-related health status in STEMI patients with multivessel CAD remains unclear.
Purpose of the Study:
- To determine if complete revascularization improves angina status in STEMI patients with multivessel CAD.
- To compare angina-free status between complete revascularization and culprit lesion-only PCI strategies.
Main Methods:
- Secondary analysis of a randomized, multinational, open-label trial involving 4041 STEMI patients with multivessel CAD.
- Patients were randomized to complete revascularization (additional PCI for significant nonculprit lesions) or culprit lesion-only PCI.
- Angina status assessed using the Seattle Angina Questionnaire Angina Frequency (SAQ-AF) score at a median 3-year follow-up.
Main Results:
- Complete revascularization led to a higher proportion of angina-free patients (87.5%) compared to culprit lesion-only PCI (84.3%), an absolute difference of 3.2% (P=.01).
- The mean SAQ-AF score improved significantly in both groups, with a slightly greater improvement in the complete revascularization group (9.9 vs 8.9 points, P=.006).
- Benefits were more pronounced in patients with nonculprit lesion stenosis severity of 80% or more.
Conclusions:
- Complete revascularization in STEMI patients with multivessel CAD yields a modest but significant improvement in angina-free status.
- This enhanced health status is an additional benefit to the known reduction in major cardiovascular events.
- The findings support considering complete revascularization for improving patient-reported outcomes in this population.
Importance:
In patients with multivessel coronary artery disease (CAD) presenting with ST-segment elevation myocardial infarction (STEMI), complete revascularization reduces major cardiovascular events compared with culprit lesion-only percutaneous coronary intervention (PCI). Whether complete revascularization also improves angina-related health status is unknown.
Objective:
To determine whether complete revascularization improves angina status in patients with STEMI and multivessel CAD.
Design, Setting, And Participants:
This secondary analysis of a randomized, multinational, open label trial of patient-reported outcomes took place in 140 primary PCI centers in 31 countries. Patients presenting with STEMI and multivessel CAD were randomized between February 1, 2013, and March 6, 2017. Analysis took place between July 2021 and December 2021.
Interventions:
Following PCI of the culprit lesion, patients with STEMI and multivessel CAD were randomized to receive either complete revascularization with additional PCI of angiographically significant nonculprit lesions or to no further revascularization.
Main Outcomes And Measures:
Seattle Angina Questionnaire Angina Frequency (SAQ-AF) score (range, 0 [daily angina] to 100 [no angina]) and the proportion of angina-free individuals by study end.
Results:
Of 4041 patients, 2016 were randomized to complete revascularization and 2025 to culprit lesion-only PCI. The mean (SD) age of patients was 62 (10.7) years, and 3225 (80%) were male. The mean (SD) SAQ-AF score increased from 87.1 (17.8) points at baseline to 97.1 (9.7) points at a median follow-up of 3 years in the complete revascularization group (score change, 9.9 [95% CI, 9.0-10.8]; P < .001) compared with an increase of 87.2 (18.4) to 96.3 (10.9) points (score change, 8.9 [95% CI, 8.0-9.8]; P < .001) in the culprit lesion-only group (between-group difference, 0.97 points [95% CI, 0.27-1.67]; P = .006). Overall, 1457 patients (87.5%) were free of angina (SAQ-AF score, 100) in the complete revascularization group compared with 1376 patients (84.3%) in the culprit lesion-only group (absolute difference, 3.2% [95% CI, 0.7%-5.7%]; P = .01). This benefit was observed mainly in patients with nonculprit lesion stenosis severity of 80% or more (absolute difference, 4.7%; interaction P = .02).
Conclusions And Relevance:
In patients with STEMI and multivessel CAD, complete revascularization resulted in a slightly greater proportion of patients being angina-free compared with a culprit lesion-only strategy. This modest incremental improvement in health status is in addition to the established benefit of complete revascularization in reducing cardiovascular events.
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