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PCI in Non–Infarct-Related Arteries Improves Outcomes in Patients with ST-Segment-Elevation Myocardial Infarction

September 1, 2013

PCI in Non–Infarct-Related Arteries Improves Outcomes in Patients with ST-Segment-Elevation Myocardial Infarction

  1. Howard C. Herrmann, MD

Restricting revascularization to culprit lesions during primary PCI led to a significantly higher rate of cardiac death, nonfatal MI, or refractory angina.

  1. Howard C. Herrmann, MD

What to do about major coronary stenoses in arteries other than the infarct-related one is a frequent clinical conundrum during percutaneous coronary intervention (PCI). In this single-blind, multicenter study from the U.K., 465 patients with ST-segment-elevation myocardial infarction (STEMI) and multivessel coronary artery disease were randomly assigned to undergo infarct-artery–only PCI or additional PCI in non-infarct arteries during the initial procedure, a strategy the authors termed “preventative PCI.” Of note, patients with cardiogenic shock, prior coronary artery bypass grafting, significant left main disease, or chronically occluded arteries were excluded. Ischemia testing was discouraged in the trial and staged or delayed PCI was allowed only in patients with positive ischemia findings.

The study was stopped early after a mean follow-up of 23 months because of a significant between-group difference in the primary composite endpoint of cardiac death, MI, or refractory angina, which occurred in 21 patients in the preventive-PCI group and in 53 patients in the infarct-artery–only PCI group (hazard ratio, 0.35; 95% confidence interval, 0.21–0.58; P<0.001). The reductions in risk were similar for each of the individual endpoint components as well as for repeat revascularization. Rates of procedure-related complications (stroke, bleeding, contrast nephropathy) were similar in the two groups.

Comment

In this study, multivessel percutaneous coronary intervention during primary PCI for ST-segment-elevation myocardial infarction reduced adverse events compared with the more conservative strategy of infarct-only PCI. This study does not address staged PCI before discharge, with or without ischemia testing — another popular option. Nonetheless, the findings suggest that restricting PCI in non–infarct-related arteries only to patients with refractory angina or subsequent MI is an inferior approach. Finally, they raise the question of whether preventive PCI might also be beneficial in non-STEMI.

  • Disclosures for Howard C. Herrmann, MD at time of publication Consultant / Advisory board Gerson Lehrman Group; Siemens; St. Jude Medical Speaker's bureau American College of Cardiology Foundation; Cardiovascular Institute; Cardiovascular Research Foundation; Christiana Medical Center; Coastal Cardiovascular Society; Crozer-Chester Hospital; Mayo Clinic; New York Cardiology Society Equity Micro-Interventional Devices, Inc. Grant / research support Abbott Vascular; Edwards Lifesciences; Gore; Medtronic; St. Jude Medical Editorial boards Catheterization and Cardiovascular Interventions; Circulation-Cardiovascular Interventions; Journal of Interventional Cardiology; Journal of Invasive Cardiology

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Reader Comments (4)

Iduama Kelly-Dokubo Physician, Cardiology

This study re-emphasizes the benefit of complete revascularization.
Surgical revascularization studies have previously told us this.

Kherad Omar Physician, Hospital Medicine, La Tour Hospital Geneva CH

It raised the issue of premature arrest of clinical trial.....

Pedro Amonte Physician, Cardiology, Hospital Evangelico

Very important and every day solution to a enormous problem

TAHSIN NEDUVANCHERY Fellow-In-Training, Cardiology, Govt.Medical college

The problem here is that the comparison was not done with the present standard of care - staged procedure after ischemia testing.The only conclusion we can draw is complete revascularisation is better than a partial revascularisation- are we stating the obvious

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