Complete Versus Culprit-Only Lesion Intervention in Patients With Acute Coronary Syndromes

• Published in: Journal of the American College of Cardiology Vol. 72; no. 17; pp. 1989 - 1999
• Main Authors: Rathod, Krishnaraj S., Koganti, Sudheer, Jain, Ajay K., Astroulakis, Zoe, Lim, Pitt, Rakhit, Roby, Kalra, Sundeep Singh, Dalby, Miles C., O’Mahony, Constantinos, Malik, Iqbal S., Knight, Charles J., Mathur, Anthony, Redwood, Simon, Sirker, Alexander, MacCarthy, Philip A., Smith, Elliot J., Wragg, Andrew, Jones, Daniel A.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 23.10.2018; Elsevier Limited
• Subjects: Acute coronary syndromes; Age; Aged; Cardiology; Cohort Studies; Confidence intervals; Coronary vessels; Coronary Vessels - pathology; Coronary Vessels - surgery; Datasets; Diabetes; Diabetes mellitus; Ethnicity; Female; Follow-Up Studies; Heart; Heart attacks; Heart surgery; Hospital Mortality; Humans; Hypertension; Intervention; Male; Medical imaging; Middle Aged; Mortality; Multivariate analysis; multivessel intervention; Myocardial infarction; Myocardial Revascularization - methods; Myocardial Revascularization - statistics & numerical data; Non-ST Elevated Myocardial Infarction - diagnosis; Non-ST Elevated Myocardial Infarction - mortality; Non-ST Elevated Myocardial Infarction - surgery; NSTEMI; Patients; PCI; Percutaneous Coronary Intervention - adverse effects; Percutaneous Coronary Intervention - methods; Severity of Illness Index; Success; Treatment Outcome; United Kingdom - epidemiology; Variables; Veins & arteries; United Kingdom; United Kingdom > UK; NSTEMI; multivessel intervention; CI; myocardial infarction; GP; HR; CV; MACE; TIMI; PCI; STEMI; MVD; MI
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2018.07.089

A large proportion of patients presenting with non–ST-segment elevation myocardial infarction (NSTEMI) present with multivessel disease (MVD). There is uncertainty in the role of complete coronary revascularization in this group of patients. The aim of this study was to investigate the outcomes of complete revascularization compared with culprit vessel–only intervention in a large contemporary cohort of patients undergoing percutaneous coronary intervention (PCI) for NSTEMI. The authors undertook an observational cohort study of 37,491 NSTEMI patients treated between 2005 and 2015 at the 8 heart attack centers in London. Clinical details were recorded at the time of the procedure into local databases using the British Cardiac Intervention Society (BCIS) PCI dataset. A total of 21,857 patients (58.3%) presented with NSTEMI and MVD. Primary outcome was all-cause mortality at a median follow-up of 4.1 years (interquartile range: 2.2 to 5.8 years). A total of 11,737 (53.7%) patients underwent single-stage complete revascularization during PCI for NSTEMI, rates that significantly increased during the study period (p = 0.006). Those patients undergoing complete revascularization were older and more likely to be male, diabetic, have renal disease and a history of previous myocardial infarction/revascularization compared with the culprit-only revascularization group. Although crude, in-hospital major adverse cardiac event rates were similar (5.2% vs. 4.8%; p = 0.462) between the 2 groups. Kaplan-Meier analysis demonstrated significant differences in mortality rates between the 2 groups (22.5% complete revascularization vs. 25.9% culprit vessel intervention; p = 0.0005) during the follow-up period. After multivariate Cox analysis (hazard ratio: 0.90; 95% confidence interval: 0.85 to 0.97) and the use of propensity matching (hazard ratio: 0.89; 95% confidence interval: 0.76 to 0.98) complete revascularization was associated with reduced mortality. In NSTEMI patients with MVD, despite higher initial (in-hospital) mortality rates, single-stage complete coronary revascularization appears to be superior to culprit-only vessel PCI in terms of long-term mortality rates. This supports the need for further randomized study to confirm these findings. [Display omitted]