Culprit Vessel Versus Multivessel Intervention at the Time of Primary Percutaneous Coronary Intervention in Patients With ST-Segment–Elevation Myocardial Infarction and Multivessel Disease

Abstract

Background-It is estimated that up to two thirds of patients presenting with ST-segment-elevation myocardial infarction have multivessel disease. The optimal strategy for treating nonculprit disease is currently under debate. This study provides a real-world analysis comparing a strategy of culprit-vessel intervention (CVI) versus multivessel intervention at the time of primary percutaneous coronary intervention in patients with ST-segment-elevation myocardial infarction. Methods and Results-We compared CVI versus multivessel intervention in 3984 patients with multivessel disease undergoing primary percutaneous coronary intervention between 2004 and 2011 at all 8 tertiary cardiac centers in London. Multivariable-adjusted models were built to determine independent predictors for in-hospital major adverse cardiovascular events (MACEs) and all-cause mortality at 1 year. To reduce confounding and bias, propensity score methods were used. CVI was associated with reduced in-hospital MACE (4.6% versus 7.2%; P=0.010) and mortality at 1 year (7.4% versus 10.1%; P=0.031). CVI was an independent predictor for reduced in-hospital MACE (odds ratio, Key Words: culprit artery ◼ multivessel percutaneous coronary intervention ◼ primary percutaneous coronary intervention ◼ ST-segment elevation myocardial infarction

Outcomes after multivessel or culprit‐Vessel intervention for ST‐elevation myocardial infarction in patients with multivessel coronary disease: A Bayesian cross‐design meta‐analysis

“…We identified 18 studies that met criteria for review. Studies were included if they were: (1) either a RCT of any size, or an observational study containing more than 25 patients per treatment arm, (2) were published in a peer reviewed journal, and (3) reported mortality rates for patients undergoing either MVI or CVI‐only at the time of primary PCI.…”

How Should We Treat Myocardial Infarction Patients With Multivessel Disease? – Staged Revascularization? Or Stent Them All Acutely? –

“…In contrast, in STEMI patients with MVD but without hemodynamic deterioration, acute multivessel PCI was not clinically beneficial and might be harmful. 7 Recently, 3 randomized trials (Table) have tried to answer the clinical questions regarding optimal management of STEMI patients with obstructive nonculprit lesions. 8- 10 In the Preventive Angioplasty in Acute Myocardial Infarction (PRAMI) trial, 10 Wald et al found a 65% reduction in the primary composite endpoint of cardiac death, MI, or refractory angina within 23 months after complete revascularization of all obstructive (≥50% stenosis) nonculprit lesions during the index procedure.…”

Fractional Flow Reserve in Acute Myocardial Infarction: A Guide for Non-Culprit Lesions?

“…However, large registries have reported conflicting outcomes and generally the opposite [6–12]. In some of these registries, the culprit-only strategy has even been associated with a lower mortality than complete multi-vessel revascularization.…”