Single-Stage Percutaneous Coronary Intervention Superior to Multi-Stage in NSTEMI Patients

SMILE trial results suggest complete single-stage revascularization is superior for NSTEMI patients.

Complete single-stage coronary revascularization was superior to multistage percutaneous coronary intervention (PCI) to reduce major adverse cardiovascular and cerebrovascular events (MACCE) in patients with multivessel non-ST-segment elevation myocardial infarction (NSTEMI).

The SMILE (Impact of Different Treatment in Multivessel Non ST Elevation Myocardial Infarction Patients: One Stage vs Multistaged Percutaneous Coronary Intervention) trial compared long-term outcomes of MACCE in1-stage PCI during the index procedure against multistage PCI in 584 patients (1-stage n=264; multistage n=263). The primary end point was defined as the incidence of MACCE (eg, death, cardiac death, reinfarction, rehospitalization for unstable angina, repeat coronary revascularization, and stroke at 1 year).

The study results, published in the Journal of the American College of Cardiology, concluded that, “1) 1-stage complete coronary revascularization is superior to multistage complete coronary revascularization in terms of MACCE; 2) this is mainly due to an unexplained higher incidence of TVR [target vessel revascularization]; 3) the intention-to-treat analysis showed a net trend in favor of [1-stage] PCI in terms of overall death; 4) the 1-stage strategy…is associated with a significantly lower incidence of minimal bleeding and a rapid decrease in myocardial enzymes.”

The rate of major adverse events was 13.63% (n=36) in the 1-stage group and 23.19% (n=61) in the multistage group (hazard ratio [HR]: 0.549; confidence interval [CI] 95%: 0.363 -0.828; P=.004).

Target revascularization at 1 year was 15.20% (n=40) in the multistage group vs 8.33% (n=22) in the 1-stage group (HR: 0.522; 95% CI: 0.310-0.878; P=.01).

No significant differences were observed when researchers limited the analyses to cardiac death (1-stage vs multistage, HR: 0.624; 95% CI: 0.270-1.441; P=.27) and myocardial infarction (1-stage vs multistage, HR: 0.678; 95% CI: 0.156-2.657; P=.46).

“Longer-term follow-up studies are needed to assess the comparative mortality benefit of performing complete coronary revascularization during index procedures, rather than delaying intervention on lesions in nonculprit vessels in patients with NSTEMI,” the authors noted.


Sardella G, Lucisano L, Garbo R, et al. Single-staged compared with multi-staged PCI in multivessel NSTEMI patients: the SMILE trial. J Am Coll Cardiol. 2016; 67(3):264-72. doi: 10.1016/j.jacc.2015.10.082.