Culprit-vessel PCI in STEMI improves outcomes through 1 year

For multivessel disease, “if it isn’t broken, don’t fix it” may also apply to PCI. A retrospective look at a London cohort points to treating only the culprit vessel of STEMI as the best method for improved patient outcomes through one year.

Current guidelines from the American Heart Association, American College of Cardiology and European Society of Cardiology discourage the use of PCI in noninfarct arteries during primary PCI unless patients have ongoing ischemia or are in cardiogenic shock.

M. Bilal Iqbal, MD, from the Royal Brompton and Harefield NHS Foundation Trust at Harefield Hospital in Middlesex, United Kingdom, and colleagues obtained data from the British Cardiac Intervention Society databases on London’s eight tertiary cardiac centers for their analysis. Between 2005 and 2011, 3,984 consecutive STEMI patients with multivessel disease were treated with primary PCI; 555 patients who had multiple vessels treated and 3,429 who had only culprit vessels treated.

The team found rates for mortality were lower among those who underwent culprit-vessel intervention as opposed to multivessel disease, 4.7 percent vs. 7.7 percent, respectively, at 30 days. Mortality remained lower in at one year in the culprit-vessel intervention group (7.4 percent vs. 10.1 percent).

Culprit vessel intervention also had a lower major adverse events rate (4.6 percent vs. 7.2 percent). Fewer patients died (3.5 percent vs. 6.1 percent) in hospital following culprit vessel intervention and these patients had lower reinfarction (0.2 percent vs. 0.8 percent) and reintervention (0.1 percent vs. 1.1 percent) rates than their multivessel treated counterparts.

“Our findings suggest that leaving stable nonculprit disease at the time of index intervention does not seem to be associated with increased risk of in-hospital recurrent ischemic events,” they wrote.

Once patients left the hospital, culprit vessel intervention had less than half the risk of mortality in the first 30 days. At one year, the culprit vessel intervention hazard ratio was only 0.65. These risks were further reduced when Iqbal et al adjusted for severe left ventricular dysfunction and call-to-balloon time.

Findings from other studies have been variable on whether multivessel treatment or culprit-vessel treatment is more effective for long-term success. As Iqbal et al noted, other patient factors may have influenced some of the treatment decisions in this real-world setting. Nevertheless, their findings support current guidelines and suggest clinicians are, largely, following them.

This study was published online Nov. 4 in Circulation: Cardiovascular Quality & Outcomes.