Culprit Vessel–Only Strategy Compared to Routine Multivessel Intervention
May 4, 2018—The Society for Cardiovascular Angiography and Interventions (SCAI) announced that findings from a study comparing culprit vessel intervention (CVI) to multivessel intervention (MVI) were presented at the 2018 SCAI scientific sessions, held April 25–28 in San Diego, California.
The contemporary, real-world analysis showed lower mortality rates when culprit-only intervention is used for patients with multivessel disease (MVD) and acute myocardial infarction (AMI) with cardiogenic shock (CS).
SCAI stated that the background of the study is that in patients with AMI and CS, percutaneous coronary intervention (PCI) of the culprit vessel is associated with improved outcomes. However, a large majority of these patients have MVD. The study sought to determine whether or not PCI of nonculprit disease in the acute setting improves outcomes.
The study evaluated all-cause mortality at 30 days and 1 year for CVI versus MVI in 649 patients with AMI, CS, and MVD. The patients were enrolled in the British Columbia Cardiac Registry from 2008 to 2014. The study's Lead Investigator is Bilal Iqbal, MD, with Victoria Heart Institute Foundation in Victoria, British Columbia.
As summarized in the SCAI announcement, CVI versus MVI was associated with lower mortality at 30 days (23.7% vs 34.5%) and 1 year (32.6% vs 44.3%). CVI was an independent predictor for survival at 30 days (hazard ratio [HR], 0.78; 95% confidence interval [Cl], 0.64–0.97; P = .023) and 1 year (HR, 0.78; 95% Cl, 0.64–0.97; P = .023). The findings were confirmed in propensity-matched cohorts. Overall, in patients with AMI and CS, a CVI approach was associated with lower mortality.
The investigators called for more randomized studies to further evaluate the two PCI strategies for this patient population in order to gain a better understanding of the safety and feasibility of culprit-only lesion approach, noted SCAI.
According to the society, this is the most recent study to compare the two PCI strategies in this patient population. The recent randomized CULPRIT-SHOCK trial was the first to find that revascularization of all significant nonculprit lesions worsens outcomes. The CULPRIT-SHOCK findings were published by Holger Thiele, MD, et al in The New England Journal of Medicine (2017;377:2419–2432).
Dr. Iqbal commented in the SCAI press release, “The comparison between culprit-only and multivessel intervention is a hot topic of conversation and debate in our field, and the results of our study add to the recent CULPRIT-SHOCK trial and help us better understand the positive outcomes of a culprit-only approach."
Dr. Iqbal continued, “The CULPRIT-SHOCK trial is the largest body of randomized evidence in the CS population. The recent Korean registry has shown that MVI may be better, but there are differences in the definition of MVI, making comparison difficult. Importantly, in CULPRIT-SHOCK and our study, MVI was defined as nonculprit PCI at the time of index intervention, and CVI was defined as PCI of culprit vessel only at the time of index intervention. Whereas in the Korean registry, MVI included nonculprit PCI, even if it were performed as an in-hospital staged procedure. Thus, it is conceivable that by adopting the definition of CVI used in our study and CULPRIT-SHOCK, the Korean study may have yielded different results.”