Optimal Revascularization Strategy in Non–ST‐Segment–Elevation Myocardial Infarction With Multivessel Coronary Artery Disease: Culprit‐Only Versus One‐Stage Versus Multistage Revascularization

Abstract

Background Few studies have investigated optimal revascularization strategies in non–ST‐segment–elevation myocardial infarction with multivessel disease. We investigated 3‐year clinical outcomes according to revascularization strategy in patients with non–ST‐segment–elevation myocardial infarction and multivessel disease. Methods and Results This retrospective, observational, multicenter study included patients with non–ST‐segment–elevation myocardial infarction and multivessel disease without cardiogenic shock. Data were analyzed at 3 years according to the percutaneous coronary intervention strategy: culprit‐only revascularization (COR), 1‐stage multivessel revascularization (MVR), and multistage MVR. The primary outcome was major adverse cardiac events (MACE: a composite of all‐cause death, nonfatal spontaneous myocardial infarction, or any repeat revascularization). The COR group had a higher risk of MACE than those involving other strategies (COR versus 1‐stage MVR; hazard ratio, 0.65; 95% CI, 0.54–0.77; P <0.001; and COR versus multistage MVR; hazard ratio, 0.74; 95% CI, 0.57–0.97; P =0.027). There was no significant difference in the incidence of MACE between 1‐stage and multistage MVR (hazard ratio, 1.14; 95% CI, 0.86–1.51; P =0.355). The results were consistent after multivariate regression, propensity score matching, inverse probability weighting, and Bayesian proportional hazards modeling. In subgroup analyses stratified by the Global Registry of Acute Coronary Events score, 1‐stage MVR lowered the risk of MACE compared with multistage MVR in low‐to‐intermediate risk patients but not in patients at high risk. Conclusions MVR reduced 3‐year MACE in patients with non–ST‐segment–elevation myocardial infarction and multivessel disease compared with COR. However, 1‐stage MVR was not superior to multistage MVR for reducing MACE except in low‐to‐intermediate risk patients.

Acute and one-year clinical outcomes of pre-stenting intravascular ultrasound: a patient-level meta-analysis of randomised clinical trials

“…Likewise, in patients with NSTEMI, an observational study suggested that multivessel revascularization reduced 3-year rates of major adverse cardiac events (MACE) (total death, MI, any revascularization) compared with culprit-vesselonly revascularization [34]. However, in this study, 1-stage multivessel revascularization was not superior to multistage revascularization except in low-to intermediate risk patients [34].…”

“…Several new metaanalyses, including data from the COMPLETE trial, comparing complete vs. culprit-only revascularization in STEMI patients supported the value of complete revascularization to reduce rates of re-infarction, cardiovascular mortality, and repeat revascularization with no difference in all-cause mortality [33]. Likewise, in patients with NSTEMI, an observational study suggested that multivessel revascularization reduced 3-year rates of major adverse cardiac events (MACE) (total death, MI, any revascularization) compared with culprit-vesselonly revascularization [34]. However, in this study, 1-stage multivessel revascularization was not superior to multistage revascularization except in low-to intermediate risk patients [34].…”

Comparison of Different Timing of Multivessel Intervention During Index-Hospitalization for Patients With Acute Myocardial Infarction

“…Several earlier studies have examined the impact of multivessel PCI on AMI patients with various inclusion criteria, timing of non-culprit vessel PCI, statisticalheterogeneity, endpoints, and conclusions. Because of conflicting results and lack of robust evidence, there is divergent clinical practice (10)(11)(12)(13)(14)(15)(16). Current guidelines suggested that PCI of non-infarct arteries should be considered in STEMI patients with the multivessel disease before hospital discharge, either at the time of primary PCI or as a planned staged procedure (18)(19)(20).…”

“…Recently, another national registry data from Korea found that complete revascularization reduced major adverse cardiac events compared with culprit-only PCI. However, there was no benefit with either immediate multivessel revascularization or staged multivessel revascularization ( 16 ). After risk stratification by the Global Registry of Acute Coronary Events (GRACE) score, immediate multivessel PCI's potential benefit was only found in low-to-intermediate risk NSTEMI patients.…”

“…Current evidence does not support routine immediate multivessel PCI in the AMI patients with cardiogenic shock and multivessel disease (9). For the remaining AMI patients with multivessel disease but no cardiogenic shock, the timing of intervention for non-culprit lesions is still an unanswered issue (10)(11)(12)(13)(14)(15)(16). Therefore, this nationwide cohort study aimed to evaluate the impact of the different timing of multivessel PCI on survival in patients after first AMI.…”