Multivessel vs culprit-only percutaneous coronary intervention among patients 65 years or older with acute myocardial infarction

doi:10.1016/j.ahj.2015.10.017

American Heart Journal

Volume 172, February 2016, Pages 9-18

https://doi.org/10.1016/j.ahj.2015.10.017 Get rights and content

Background

Older adults presenting with acute myocardial infarction (MI) often have multivessel coronary artery disease amenable to percutaneous coronary intervention (PCI), yet the risks of multivessel intervention may outweigh potential benefits in these patients. We sought to determine if nonculprit intervention during the index PCI is associated with better outcomes among older patients with acute MI and multivessel disease.

Methods

We examined 19,271 ST-segment elevation MI (STEMI) and 31,361 non-STEMI (NSTEMI) patients 65 years or older with multivessel disease in a linked CathPCI Registry–Medicare database, excluding patients with prior coronary artery bypass grafting, left main disease, or cardiogenic shock. Using inverse probability-weighted propensity adjustment, we compared mortality between patients receiving culprit-only vs multivessel intervention during the index PCI procedure.

Results

Most older MI patients (91% STEMI and 74% NSTEMI) received culprit-only intervention during the index PCI. Among STEMI patients, multivessel intervention during the index PCI was associated with higher 30-day mortality (8.3% vs 6.3%, adjusted hazard ratio [HR] 1.36, 95% CI 1.14-1.62) than culprit-only intervention, and this trend persisted at 1 year (13.8% vs 12.2%, adjusted HR 1.14, 95% CI 0.99-1.31). No significant mortality differences were observed among NSTEMI patients at 30 days (3.4% vs 4.1%, adjusted HR 1.01, 95% CI 0.88-1.15) or at 1 year (10.1% vs 10.8%, adjusted HR 0.99, 95% CI 0.91-1.08).

Conclusions

Nonculprit intervention during the index PCI was associated with worse outcomes among STEMI patients, but not NSTEMI patients.

Section snippets

Study population

The CathPCI Registry, an initiative of the ACC and the Society for Cardiovascular Angiography and Interventions, is the largest US clinical registry of patients undergoing diagnostic cardiac catheterization and PCI. Details of the CathPCI Registry have been previously described.¹³ In brief, trained data abstractors at each participating hospital collect detailed baseline clinical characteristics, in-hospital care processes, and outcomes retrospectively via medical record review using a

Hospital and patient characteristics

Among patients 65 years or older with acute MI and multivessel disease treated with PCI, most (17,514 STEMI [91%] and 23,344 NSTEMI [74%] patients) underwent culprit-only intervention during the index PCI procedure.

Baseline hospital and patient characteristics comparing patients who underwent culprit-only vs multivessel intervention during the index PCI procedure are presented in Table I. Multivessel intervention during the index PCI for STEMI was more often performed in rural communities or

Discussion

Several insights emerge from this large retrospective study of patients 65 years or older undergoing PCI for an acute MI. A non–infarct-related vessel was treated during the index PCI procedure in approximately 1 in 10 STEMI patients and 1 in 4 NSTEMI patients with multivessel disease. Among STEMI patients, multivessel intervention during the index PCI procedure was associated with higher short-term mortality, but no significant difference in long-term mortality compared with culprit-only PCI.

Conclusions

To our knowledge, this is the largest study of older patients presenting with acute MI and multivessel coronary artery disease. We observed most patients to undergo culprit-only intervention during the index PCI. Multivessel intervention during the index procedure was associated with higher 30-day mortality among STEMI patients, and there were no significant differences in long-term mortality among both STEMI and NSTEMI patients when compared with culprit-only PCI.

Disclosures

Dr Wang reports research grants to the DCRI from Eli Lilly, Daiichi Sankyo, Gilead Sciences, Glaxo Smith Kline, the American College of Cardiology, and the American Society of Nuclear Cardiology, as well as honoraria from Astra Zeneca and the American College of Cardiology. Ms McCoy, Dr Rao, Dr Resnic, Dr Cavender, and Dr Messenger have no relevant disclosures to report. Dr Bhatt discloses the following relationships: advisory board: Cardax, Elsevier Practice Update Cardiology, Medscape

Acknowledgements

The authors would like to thank Erin Hanley, MS, for her editorial contributions to this manuscript. Ms Hanley did not receive compensation for her assistance, apart from her employment at the institution where this study was conducted.

References (40)

V. Fuster et al.
Atherothrombosis and high-risk plaque: part I: evolving concepts
J Am Coll Cardiol
(2005)
M.H. Shishehbor et al.
In unstable angina or non–ST-segment acute coronary syndrome, should patients with multivessel coronary artery disease undergo multivessel or culprit-only stenting?
J Am Coll Cardiol
(2007)
R. Kornowski et al.
Prognostic impact of staged versus “one-time” multivessel percutaneous intervention in acute myocardial infarction: analysis from the HORIZONS-AMI (harmonizing outcomes with revascularization and stents in acute myocardial infarction) trial
J Am Coll Cardiol
(2011)
P.J. Vlaar et al.
Culprit vessel only versus multivessel and staged percutaneous coronary intervention for multivessel disease in patients presenting with ST-segment elevation myocardial infarction: a pairwise and network meta-analysis
J Am Coll Cardiol
(2011)
E.A. Amsterdam et al.
2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
J Am Coll Cardiol
(2014)
A.H. Gershlick et al.
Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel disease: the CvLPRIT trial
J Am Coll Cardiol
(2015)
R.G. Brindis et al.
The American College of Cardiology–National Cardiovascular Data Registry (ACC-NCDR): building a national clinical data repository
J Am Coll Cardiol
(2001)
B.G. Hammill et al.
Linking inpatient clinical registry data to Medicare claims data using indirect identifiers
Am Heart J
(2009)
S.R. Cole et al.
Adjusted survival curves with inverse probability weights
Comput Methods Programs Biomed
(2004)
S.F. Kelsey et al.
Results of percutaneous transluminal coronary angioplasty in patients greater than or equal to 65 years of age (from the 1985 to 1986 National Heart, Lung, and Blood Institute's Coronary Angioplasty Registry)
Am J Cardiol
(1990)

C. Rizo-Patron et al.

Percutaneous transluminal coronary angioplasty in octogenarians with unstable coronary syndromes

Am J Cardiol

(1990)

J. Zahavi et al.

Enhanced in vivo platelet release reaction and malondialdehyde formation in patients with hyperlipidemia

Am J Med

(1981)

C. Heiss et al.

Impaired progenitor cell activity in age-related endothelial dysfunction

J Am Coll Cardiol

(2005)

E.L. Hannan et al.

Culprit vessel percutaneous coronary intervention versus multivessel and staged percutaneous coronary intervention for ST-segment elevation myocardial infarction patients with multivessel disease

JACC Cardiovasc Interv

(2010)

N. Gonzalo et al.

Incomplete stent apposition and delayed tissue coverage are more frequent in drug-eluting stents implanted during primary percutaneous coronary intervention for ST-segment elevation myocardial infarction than in drug-eluting stents implanted for stable/unstable angina: insights from optical coherence tomography

JACC Cardiovasc Interv

(2009)

G. Sianos et al.

Angiographic stent thrombosis after routine use of drug-eluting stents in ST-segment elevation myocardial infarction: the importance of thrombus burden

J Am Coll Cardiol

(2007)

G.E. El-Hayek et al.

Meta-analysis of randomized controlled trials comparing multivessel versus culprit-only revascularization for patients with ST-segment elevation myocardial infarction and multivessel disease undergoing primary percutaneous coronary intervention

Am J Cardiol

(2015)

Z. Kalarus et al.

Importance of complete revascularization in patients with acute myocardial infarction treated with percutaneous coronary intervention

Am Heart J

(2007)

S.J. Brener et al.

Efficacy and safety of multivessel percutaneous revascularization and tirofiban therapy in patients with acute coronary syndromes

Am J Cardiol

(2002)

S.J. Brener et al.

Culprit-only or multivessel revascularization in patients with acute coronary syndromes: an American College of Cardiology National Cardiovascular Database Registry report

Am Heart J

(2008)

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Second, the presence of residual “anatomic” CAD after functionally complete revascularization has no impact on prognosis.31 Third, the occurrence of procedural complications, especially those impacting the prognosis such as periprocedural MI and Contrast Induced-Acute Kidney Injury (CI-AKI), is directly proportional to both age and number of treated vessels.32-37 Fourth, periprocedural complications are associated with a worse prognostic impact in elderly patients.32-37
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The FIRE trial is a prospective, randomized, international, multicenter, open-label study with blinded adjudicated evaluation of outcomes. Patients aged 75 years and older, with MI (either STE or NSTE), MVD at coronary artery angiography, and a clear culprit lesion will be randomized to culprit-only treatment or to physiology-guided complete revascularization. The primary end point will be the patient-oriented composite end point of all-cause death, any MI, any stroke, and any revascularization at 1 year. The key secondary end point will be the composite of cardiovascular death and MI. Quality of life and physical performance will be evaluated as well. All components of the primary and key secondary outcome will be tested also at 3 and 5 years. The sample size for the study is 1,400 patients.
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Age, gender, and clinical risk factors were similar between MVR and CVR groups. Of the studies included, 2 were post-hoc analyses of randomized controlled trials5,6 that included 3,154 patients, and 13 were retrospective analyses of observational cohort studies that included 168,125 patients.7–19 With respect to short-term outcomes (in-hospital to 30 days) (Figure 5), MVR was significantly associated with higher rates of the composite end point of MACE and compared with CVR.
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View all citing articles on Scopus

: Alice K. Jacobs, MD served as guest editor for this article.

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Clinical InvestigationMultivessel vs culprit-only percutaneous coronary intervention among patients 65 years or older with acute myocardial infarction

Background

Methods

Results

Conclusions

Section snippets

Study population

Hospital and patient characteristics

Discussion

Conclusions

Disclosures

Acknowledgements

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

Comput Methods Programs Biomed

Am J Cardiol

Am J Cardiol

Am J Med

J Am Coll Cardiol

JACC Cardiovasc Interv

JACC Cardiovasc Interv

J Am Coll Cardiol

Am J Cardiol

Am Heart J

Am J Cardiol

Am Heart J

Clinical Investigation
Multivessel vs culprit-only percutaneous coronary intervention among patients 65 years or older with acute myocardial infarction