Two Studies Support Staged PCI for Multivessel Disease in STEMI Patients

August 9, 2011—In the Journal of the American College of Cardiology, Pieter J. Vlaar, MD, et al published findings from a study that sought to investigate whether, in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD), percutaneous coronary intervention (PCI) should be confined to the culprit vessel or also include nonculprit vessels and, when performing PCI for nonculprit vessels, whether it should take place during primary PCI or staged procedures (2011;58:692–703). The background of the study is that a significant percentage of STEMI patients have MVD. However, the best PCI strategy for nonculprit vessel lesions is unknown, the investigators noted.

As detailed in the Journal of the American College of Cardiology, the investigators performed pairwise and network meta-analyses on three PCI strategies for MVD in STEMI patients: (1) culprit vessel-only PCI strategy (culprit PCI), defined as PCI confined to culprit vessel lesions only; (2) multivessel PCI strategy (MV-PCI), defined as PCI of culprit vessel as well as one or more nonculprit vessel lesions; and (3) staged PCI strategy (staged PCI), defined as PCI confined to culprit vessel, after which one or more nonculprit vessel lesions are treated during staged procedures. Prospective and retrospective studies were included when research subjects were patients with STEMI and MVD undergoing PCI. The primary endpoint was short-term mortality.

The investigators reported that four prospective and 14 retrospective studies involving 40,280 patients were included in the study. Pairwise meta-analyses demonstrated that staged PCI was associated with lower short- and long-term mortality as compared with culprit PCI and MV-PCI, and that MV-PCI was associated with highest mortality rates at both short- and long-term follow-up. In network analyses, staged PCI was also consistently associated with lower mortality.

The investigators concluded that this meta-analysis supports current guidelines discouraging performance of multivessel primary PCI for STEMI. When significant nonculprit vessel lesions are suitable for PCI, they should only be treated during staged procedures, the investigators advised.

In a second study published in the Journal of the American College of Cardiology, Ran Kornowski, MD, et al concluded that a deferred angioplasty strategy of nonculprit lesions should remain the standard approach in patients with STEMI undergoing primary PCI, as multivessel PCI may be associated with a greater hazard for mortality and stent thrombosis (2011;58;704–711).

In an analysis from the HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) trial, the investigators sought to determine the prognostic impact of staged versus one-time multivessel PCI in acute myocardial infarction.

The investigators compared a one-time primary PCI of the culprit and nonculprit lesions with PCI of only the culprit lesion and staged nonculprit PCI at a later date in patients with STEMI and multivessel disease. In patients with STEMI and multivessel disease, it is unknown whether it is safe or even desirable to also treat the nonculprit vessel during the primary PCI procedure, noted the investigators.

As detailed in the Journal of the American College of Cardiology, 668 (18.5%) of the 3,602 STEMI patients enrolled in the HORIZONS-AMI trial underwent PCI of culprit and nonculprit lesions for multivessel disease. Patients were categorized into a single PCI strategy (n = 275) versus staged PCI (n = 393). The endpoints analyzed included the 1-year rates of major adverse cardiovascular events and its components, death, reinfarction, target-vessel revascularization for ischemia, and stroke.

The investigators found that single versus staged PCI was associated with higher 1-year mortality (9.2% vs 2.3%; hazard ratio [HR]: 4.1, 95% confidence interval [CI]: 1.93–8.86; P < .0001), cardiac mortality (6.2% vs 2%; HR: 3.14, 95% CI: 1.35–7.27; P = .005), definite/probable stent thrombosis (5.7% vs 2.3%; HR: 2.49, 95% CI: 1.09-5.70; P = .02), and a trend toward greater major adverse cardiovascular events (18.1% vs 13.4%; HR: 1.42, 95% CI: 0.96–2.1; P = .08). The mortality advantage favoring staged PCI was maintained in a subgroup of patients undergoing truly elective multivessel PCI. Also, the staged PCI strategy was independently associated with lower all-cause mortality at 30 days and at 1 year, reported the investigators.