Immediate vs. staged multivessel PCI: How the 2 strategies compare when treating STEMI patients
When treating STEMI patients who present with multivessel coronary artery disease (CAD), immediate complete revascularization is noninferior to percutaneous coronary intervention (PCI) of the culprit lesion followed by a delayed treatment of all other lesions, according to new research presented at ESC Congress 2023, the annual meeting of the European Society of Cardiology.
The findings were simultaneously published in the New England Journal of Medicine.[1]
“Whereas current guidelines recommend complete revascularization in patients with STEMI and multivessel CAD, the time at which revascularization of nonculprit lesions should be performed—immediately, during the index procedure, or in a staged strategy, after the index procedure—remains unknown,” wrote lead author Barbara E. Stähli, MD, MPH, a cardiologist with University Hospital Zurich in Switzerland, and colleagues.
For the MULTISTARS AMI trial, Stähli et al. examined data from 418 patients randomized to undergo immediate multivessel PCI and another 422 patients who underwent staged multivessel PCI, with the nonculprit lesions being treated 19 to 45 days after the initial procedure. Patients were treated at one of 37 facilities in Europe from October 2016 to June 2022. All were in hemodynamically stable condition at the time of randomization.
The study’s primary endpoint was a composite of all-cause mortality, nonfatal myocardial infarction (MI), stroke, unplanned ischemia-driven revascularization or heart failure hospitalization within one year. This was seen in 8.5% of patients who underwent immediate multivessel PCI and 16.3% of patients who underwent staged multivessel PCI. Nonfatal MI and stroke were more likely among the staged multivessel PCI group, but other outcomes were comparable between the two treatment options.
“Unstable plaque features in nonculprit lesions that have been described in patients with STEMI may confer a predisposition to plaque rupture and subsequent coronary events when PCI of nonculprit lesions is performed as a staged intervention,” the authors wrote. “Improved coronary blood flow in nonculprit vessels after immediate multivessel PCI may reduce the ischemic burden during the early phase of a STEMI event”
The group also noted that immediate multivessel PCI may reduce total contrast volume and radiation exposure in addition to limiting the need for later revascularization procedures or additional hospitalizations. Another potential benefit is that some patients may simply prefer to get everything done immediately as opposed to waiting.
Stähli and colleagues also highlighted some potential limitations to their research, including the fact that they began during the COVID-19 pandemic, which may have delayed some procedures and impacted the group’s ability to enroll patients. In addition, patients presenting with cardiogenic shock, left main coronary artery disease, chronic total occlusion or previous coronary artery bypass graft surgery were excluded, meaning these findings do not apply to those populations.
Read the full analysis here. Additional ESC Congress 2023 coverage is available here.
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.