Complete Revascularization Superior to Culprit-Only Intervention in NSTEMI

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Single-stage complete coronary revascularization appears to be superior to culprit-only lesion intervention in multivessel disease ACS.
Single-stage complete coronary revascularization appears to be superior to culprit-only lesion intervention in multivessel disease ACS.

Single-stage complete coronary revascularization appears to be superior to culprit-vessel–only (CV-only) percutaneous coronary intervention (PCI) in terms of long-term mortality rates for patients with non–ST segment elevation myocardial infarction (NSTEMI), according to a study published in the Journal of the American College of Cardiology.

Researchers analyzed the frequency and long-term outcomes of complete revascularization compared with CV-only PCI in a cohort of successive patients with multivessel disease (MVD) undergoing PCI for NSTEMI.

The study examined data from 37,491 patients with NSTEMI who were treated between 2005 and 2015. Of the patients examined, 58.3% (21,857) presented with NSTEMI and MVD. The primary outcome of the study was all-cause mortality at a median follow-up of 4.1 years (interquartile range [IQR]: 2.2-5.8 years).

Patients were classified into two groups: CV-only intervention or complete revascularization. Long-term all-cause mortality was recorded from a national database.

The mean age of participants was 67.3 years, and 74.3% were men. In total, 53.7% (11,737) patients underwent complete revascularization during their PCI (complete revascularization group), while 46.3% (10,120) of patients did not (CV group). Over time, the frequency of MVD increased from 26.3% in 2005 to 35.9% in 2015.

Patients who underwent complete revascularization were older and female and had both kidney disease and a history of previous myocardial infarction.

Regarding short-term outcomes, the complete revascularization group had higher death rates but lower rates of reintervention PCI. Major adverse cardiac events rates were similar in both groups (3.8% in the culprit group vs 4.1% in the complete revascularization group; P =.462). Long-term outcomes (IQR: 2.2-6.2 years) showed a statistically significant difference in mortality rates between the 2 groups (25.9% culprit only group vs 22.5% complete revascularization group; P =.0005).

Complete revascularization was associated with reduced rates of all-cause mortality (hazard ratio [HR], 0.86; 95% CI, 0.79-0.94) and remained a predictor of survival (HR, 0.90; 95% CI, 0.85-0.97).

Considering the period between 6 months and 5 years after treatment, patients undergoing complete revascularization had significantly reduced rates of all-cause mortality compared with CV-only treatment (HR, 0.65; 95% CI, 0.35-0.82; P =.0005).

Study limitations include the exclusion of patients with nonculprit chronic total occlusion lesions and cardiogenic shock, possibly limiting the generalizability of the results. Furthermore, data were nonrandomized. There was no clarification regarding whether complete revascularization needs to be performed in a single sitting or as a staged procedure.

The study concludes that for patients with NSTEMI with MVD, single-stage complete coronary revascularization appears to be superior to CV-only PCI in terms of long-term mortality rates.

Disclosures: Multiple authors declare associations with the pharmaceutical industry. Please refer to original reference for a full list of authors' disclosures.

Reference

Rathod KS, Koganti S, Jain AK, et al. Complete versus culprit-only lesion intervention in patients with acute coronary syndromes. J Am Coll Cardiol. 2018;72:1989–99. doi: 10.1016/j.jacc.2018.07.089

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