January 09, 2018
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Single-procedure complete revascularization may be optimal in STEMI, multivessel disease

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Sripal Bangalore, MD, MHA
Sripal Bangalore

Patients with STEMI and multivessel disease who underwent a single-procedure multivessel PCI had improved outcomes compared with those who underwent culprit-only PCI, according to a meta-analysis published in The American Journal of Cardiology.

“Single-procedure multivessel PCI during index primary PCI was considered class III in various guidelines due to increased mortality reported from observational studies,” Sripal Bangalore, MD, MHA, FACC, FAHA, FSCAI, associate professor of medicine, director of research of the cardiac catheterization laboratory and director of the Cardiovascular Outcomes Group in the Cardiovascular Clinical Research Center at NYU Langone Health, and a member of the Cardiology Today Editorial Board, and colleagues wrote. “The present meta-analysis suggests that single-procedure multivessel PCI may not only be safe, but may also reduce the risk of death or MI in patients with STEMI and [multivessel disease].”

Randomized controlled trials

Researchers analyzed data from 3,150 patients with STEMI and multivessel disease from 11 randomized controlled trials. Patients underwent staged multivessel PCI, single-procedure multivessel PCI or culprit-only PCI. Studies included in the analysis reported on outcomes of reinfarction and death during at least 6 months of follow-up.

The primary efficacy outcome of interest was the composite risk for reinfarction or death. Safety outcomes of interest included stroke, acute kidney injury and major bleeding, and other efficacy outcomes of interest were defined as MI, death and repeat revascularization.

Patients were followed up for a mean of 1.6 years, which resulted in 5,296 patient-years of follow-up.

The risk for MI and death decreased in patients who underwent single-procedure multivessel PCI vs. those with culprit-only PCI (RR = 0.52; 95% CI, 0.37-0.73), driven by reduction in MI (RR = 0.42; 95% CI, 0.25-0.69). Single-procedure multivessel PCI was also linked to a trend (P = .06) in the reduction of death compared with culprit-only PCI (RR = 0.64; 95% CI, 0.4-1.02). Staged multivessel PCI was not linked to a reduction in death or MI vs. culprit-only PCI.

Repeat revascularization

Compared with culprit-only PCI, both strategies of multivessel PCI were linked to a significantly lower risk for repeat revascularization.

Safety outcomes did not differ in the two multivessel strategies vs. culprit-only PCI. Heterogeneity or a small study effect was not seen in safety outcome analyses.

“Further study is required to determine why single-procedure multivessel PCI but not staged multivessel PCI reduced death or MI when compared with culprit-only PCI,” Bangalore and colleagues wrote. “Possible explanations follow: 1) Compared to single-procedure multivessel PCI, the delay between the index and staged procedures may have been too long to prevent recurrent events; 2) Earlier PCI may promote faster and/or more complete recovery of left ventricular function with less hemodynamic instability and fewer arrhythmias; 3) The difference may merely reflect ascertainment bias (ie, in contrast to staged multivessel PCI, periprocedural MI is difficult to detect with single-procedure multivessel PCI given the ongoing acute infarct process with rising biomarkers).” – by Darlene Dobkowski

Disclosures: The authors report no relevant financial disclosures.