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Complete Revascularization Versus Culprit-Only Percutaneous Coronary Intervention in Non-ST-Elevation Myocardial
Mohamed Hamouda Elkasaby1, Alaa Ayyadhah Alanazi2, William H Frishman3
1From the Department of Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
Insights
Complete revascularization for non-ST-elevation myocardial infarction with multivessel disease increased major bleeding events. However, it showed similar mortality and fewer recurrent heart attacks, despite longer hospital stays and higher costs.
Area of Science:
- Cardiology
- Interventional Cardiology
- Health Services Research
Background:
- Multivessel coronary artery disease (CAD) in non-ST-elevation myocardial infarction (NSTEMI) presents treatment challenges.
- Percutaneous coronary intervention (PCI) strategies include culprit-only versus complete revascularization.
- Optimal PCI strategy for NSTEMI with multivessel CAD remains debated.
Purpose of the Study:
- To compare the outcomes of complete revascularization versus culprit-only PCI in hospitalized adults with NSTEMI and multivessel CAD.
- To evaluate in-hospital major bleeding, mortality, and major adverse cardiovascular events (MACE).
Main Methods:
- Retrospective analysis of the National Inpatient Sample (2016-2022).
- Inclusion of adult NSTEMI hospitalizations with multivessel CAD, excluding complex cases.
- 1:1 propensity score matching on 52 covariates for 37,048 pairs.
Main Results:
- Complete revascularization was associated with significantly higher in-hospital major bleeding (12.22% vs 10.52%; OR 1.18).
- In-hospital mortality was similar between groups (1.01% vs 0.98%).
- Major adverse cardiovascular events trended lower with complete revascularization, driven by reduced recurrent myocardial infarction, but resulted in longer hospital stays and higher costs.
Conclusions:
- Complete revascularization in NSTEMI with multivessel CAD increases major bleeding risk, particularly in younger patients (<65 years).
- While potentially reducing recurrent MI, the increased bleeding risk and resource utilization warrant careful consideration.
- Individualized treatment strategies are crucial for optimizing outcomes in this patient population.
Abstract:
We used the National Inpatient Sample from 2016 to 2022 to compare complete revascularization with culprit-only percutaneous coronary intervention in adults hospitalized with non-ST-elevation myocardial infarction and multivessel disease. Hospitalizations complicated by cardiogenic shock, cardiac arrest, coronary artery bypass grafting, or mechanical circulatory support were excluded. Complete revascularization was defined as intervention on at least 2 native coronary territories during the index admission. We performed 1:1 propensity score matching on 52 covariates. The primary outcome was in-hospital major bleeding. Among 713,844 weighted hospitalizations (142,769 unweighted), 27.5% underwent complete revascularization. Matching yielded 37,048 well-balanced pairs (all standardized mean differences <0.01). Complete revascularization was associated with more major bleeding (12.22% vs 10.52%; odds ratio 1.18; 95% confidence interval, 1.13-1.24; P < 0.001), whereas in-hospital mortality was similar (1.01% vs 0.98%; P = 0.684). Major adverse cardiovascular events trended lower (14.61% vs 15.10%; P = 0.062), driven by less recurrent myocardial infarction (P = 0.034). Complete revascularization was also associated with a longer stay (3 vs 2 days) and higher cost ($127,536 vs $91,771; both P < 0.001). The excess bleeding was consistent across 17 subgroups and greatest in patients younger than 65 years (P for interaction < 0.001).
