Multivessel PCI Limited to a Minority of STEMI Patients

Patrice Wendling

November 13, 2020

Multivessel percutaneous coronary intervention (PCI) for patients with ST-elevation myocardial infarction (STEMI) made modest inroads over the past decade in the United States, a national registry analysis shows.

Multivessel PCI declined sharply from 42.7% in the third quarter of 2009 to a low of 32.7% in the second quarter of 2013 after the publication of observational and trial substudies suggesting no benefit or an association with higher mortality compared with the multivessel approach with culprit-lesion-only PCI.

Indeed, the American College of Cardiology Foundation/American Heart Association recommended against routine use of multivessel PCI in their 2013 STEMI guidelines.

Rates rebounded, however, after the publication of positive outcomes from the PRAMI, CvLPRIT, and COMPARE-ACUTE trials. By the time the 2015 STEMI guideline upgraded multivessel PCI to a class IIb recommendation, national use had already exceeded 40% and peaked at 44% in the fourth quarter of 2017, according to the investigators, led by Eric Secemsky, MD, MSc, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston.

Multivessel PCI use also varied substantially across the 1598 institutions analyzed, ranging from a median of 54.9% in the highest quintile hospitals to 23.9% in the lowest quintile hospitals.

Although hospitals in the highest quintile of multivessel PCI use had greater annual PCI volumes, patient characteristics were mostly similar between quintiles, the authors report online in JAMA Cardiology.

"You can go to an institution at one location and they might pursue a strategy where they fix all the lesions and you might go across town to another hospital and they might decide the best strategy is to just medically manage it," Secemsky told theheart.org | Medscape Cardiology. "So the point of that was to really just show there is a lot of heterogeneity in our clinical practice around this topic and there are a lot of changes that happen with time."

One of the biggest drivers of change will likely be last year's COMPLETE trial, in which complete revascularization was superior to culprit-lesion-only PCI for reducing the hard clinical outcomes of cardiovascular death, MI, and ischemia-driven revascularization.

Those data were not available, however, for this analysis, which examined 359,879 multivessel STEMI cases in the National Cardiovascular Data Registry's CathPCI Registry from July 2009 through March 2018.

"In the routine patient that has residual disease after a heart attack, I think we're going to see more adoption of a multivessel revascularization strategy," Secemsky said. "We kind of have the opportunity to step back if we do want to medically manage it because of ISCHEMIA but it's hard to argue with the reduction of myocardial infarction seen in COMPLETE and a lot of these people do come back for repeat revascularization later on."

That said, the investigators caution that that the rapid change seen in practice may lead to harm if there is no consensus that existing data are sufficient to promote widespread adoption.

"In areas that are data-free or where the data aren't clear, we should pay attention to the fact that maybe this is an area that we can more rapidly address through an update to a guideline or some sort of consensus document from a society, so that we really harmonize how we practice," Secemsky said.

Among the 359,879 multivessel STEMI admissions, multivessel PCI was performed in 38.5% of patients (mean age, 62.3 years; 73.9% male) within 45 days.

Multivessel PCI during the index STEMI hospitalization became the dominant strategy, increasing from 19.3% to 31.8% over the study period.

In contrast, multivessel PCI during a separate procedure after discharge declined steadily from 23.4% of STEMI cases in the third quarter of 2009 to a low of 9.9% in the fourth quarter of 2014.

Complete revascularization of all diseased arteries was achieved in 76.2% of patients who underwent multivessel PCI. Although this figure exceeded 90% in COMPLETE, the finding suggests that "most clinicians who do pursue a multivessel revascularization strategy are fixing all the main arteries that are diseased," Secemsky said.

In an accompanying editorial, John A. Bittl, MD, AdventHealth Ocala, Florida, writes that "clinicians have been forced to wade through a morass of conflicting reports and a slew of contradictory guidelines that have gone around in circles and still not reached a consensus about the timing of multivessel PCI or provided a consistent recommendation for patients with or without cardiogenic shock."

Bittl suggests that additional studies are inevitable and commended the investigators for "showing that culprit-only PCI is the preferred approach in practice and routine multivessel PCI is unpropitious. The findings indicate that clinicians have not replaced common sense with the 'uncertain, unsettled and confused' state of the evidence."

Secemsky said the statement is understandable, given that less than 50% of clinicians were performing multivessel PCI in 2018. "That conclusion was true at the time we ended our follow-up, but may not remain the conclusion among interventionalists now that the COMPLETE trial has been published."

The study was funded by the National Cardiovascular Data Registry. Secemsky is supported by the National Heart, Blood, and Lung Institute; and reports grants and personal fees from Cook, BD, Medtronic, Philips, and CSI; grants from Boston Scientific and AstraZeneca; and personal fees from Janssen and Abbott Vascular outside the submitted work.

JAMA Cardiol. Published online November 4, 2020. Abstract, Editorial

Follow Patrice Wendling on Twitter: @pwendl. For more from theheart.org | Medscape Cardiology, join us on Twitter and Facebook.

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