News

Primary PCI in STEMI: Stick to Culprit Lesions

Publish date: February 1, 2010

SNOWMASS, COLO. — Primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction and multivessel disease is best limited to the culprit vessel in hemodynamically stable patients, according to the first large population-based study on this issue to include long-term outcomes.

Staged PCI of other lesions causing residual ischemia can safely be done later during the same hospitalization or anytime in the next couple months, Dr. Spencer B. King III reported at a conference sponsored by the American College of Cardiology.

Indeed, the analysis of New York State PCI Registry data showed that risk-adjusted mortality with a strategy of staged PCI on additional vessels within 60 days was comparable to that of culprit-vessel primary PCI alone.

Prior studies examining the topic of culprit- versus multivessel PCI in STEMI patients have generally been small, short-term, and conflicting in their findings. As a result, practices vary widely, with some cardiologists restricting themselves to opening only the culprit vessel, while others opt to treat additional lesions at the time of primary PCI, and still others wait a day, several weeks, or months before addressing lesions shown on the basis of stress testing or fractional flow reserve to be a likely source of residual ischemia.

“There are a host of different opinions out there on how to deal with this,” observed Dr. King, the conference program director and president of St. Joseph's Heart and Vascular Institute, Atlanta.

To help bring clarity to the situation, he and his coinvestigators compared mortality through 42 months of follow-up in STEMI patients with multivessel disease who underwent primary PCI in New York State, where reporting of PCI outcomes is mandatory, from January 2003 through June 2006 (JACC Cardiovasc. Interv. 2010;3:22–31).

In that study, mortality rates were significantly lower in 458 hemodynamically stable patients whose revascularization was limited to the culprit vessel than in an equal number of propensity-matched patients who underwent multivessel revascularization at the time of primary PCI (see table on opposite page).

On the other hand, mortality rates in hospital and at 12, 24, and 42 months of follow-up were similar in 259 patients who underwent culprit-vessel PCI only and in 259 propensity-matched patients who had staged multivessel revascularization during the index hospitalization. In fact, the staged multivessel PCI group showed a consistent trend for fewer deaths at all time points.

Similarly, among 538 patients who underwent culprit-vessel PCI only and were alive at 60 days, mortality rates at 12, 24, and 42 months of follow-up were not statistically different compared with the rates in an equal number of propensity-matched patients who had staged multivessel revascularization within 60 days on a nonemergency basis. Once again, there was a consistent albeit statistically nonsignificant trend for lower mortality in the staged multivessel revascularization group.

A staged interventional approach to STEMI patients with multivessel disease makes solid sense to Dr. David O. Williams. “When I was at Rhode Island Hospital, the mean time it took from when the patient hit the door of the cath lab, often fully dressed, to the balloon going up, was 18 minutes,” recalled Dr. Williams, who is now director of the cardiovascular laboratory and interventional cardiology at Brigham and Women's Hospital, Boston.

“It's very tough to learn much about the patient who's undergoing primary PCI—and their ability to take dual antiplatelet therapy—given the haste with which we do these cases. We're on the clock. When you talk about multiple stents, multiple lesions, I think it might be good to have an opportunity to get to know a little bit more about the background of the patient, including any other illnesses that might relate to the decision,” he said.

Disclosures: Dr. King disclosed serving as a consultant to BG Medicine, Celonova Biosciences, Cordis, Medtronic, and NorthPoint Domain. Dr. Williams is a consultant to Abbott Vascular, Cordis, and Volcano.