Journal of the American College of Cardiology
Volume 72, Issue 17, October 2018 DOI: 10.1016/j.jacc.2018.07.089
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Original Investigation

Complete Versus Culprit-Only Lesion Intervention in Patients With Acute Coronary Syndromes

Krishnaraj S. Rathod, Sudheer Koganti, Ajay K. Jain, Zoe Astroulakis, Pitt Lim, Roby Rakhit, Sundeep Singh Kalra, Miles C. Dalby, Constantinos O’Mahony, Iqbal S. Malik, Charles J. Knight, Anthony Mathur, Simon Redwood, Alexander Sirker, Philip A. MacCarthy, Elliot J. Smith, Andrew Wragg and Daniel A. Jones

Author + information

vol. 72 no. 17 1989-1999
DOI: 
https://doi.org/10.1016/j.jacc.2018.07.089
Published By: 
Journal of the American College of Cardiology
Print ISSN: 
0735-1097
Online ISSN: 
1558-3597
History: 
  • Received March 20, 2018
  • Revision received June 29, 2018
  • Accepted July 30, 2018
  • Published online October 15, 2018.
Copyright & Usage: 
2018 American College of Cardiology Foundation

Author Information

  1. Krishnaraj S. Rathod, MDa,
  2. Sudheer Koganti, MDa,
  3. Ajay K. Jain, MDa,
  4. Zoe Astroulakis, MD, PhDb,
  5. Pitt Lim, MDb,
  6. Roby Rakhit, MDc,
  7. Sundeep Singh Kalra, MDc,
  8. Miles C. Dalby, MDd,
  9. Constantinos O’Mahony, MDa,
  10. Iqbal S. Malik, MDe,
  11. Charles J. Knight, MDa,
  12. Anthony Mathur, MD, PhDa,
  13. Simon Redwood, MDf,
  14. Alexander Sirker, MD, PhDa,
  15. Philip A. MacCarthy, MD, PhDg,
  16. Elliot J. Smith, MDa,
  17. Andrew Wragg, MD, PhDa and
  18. Daniel A. Jones, MD, PhDa,∗ (daniel.jones{at}qmul.ac.uk), @bhcintervention@BartsIntervGrp
  1. aBarts Health NHS Trust, London, United Kingdom
  2. bSt. George’s Healthcare NHS Foundation Trust, St. George’s Hospital, London, United Kingdom
  3. cRoyal Free London NHS Foundation Trust, London, United Kingdom
  4. dRoyal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, Middlesex, London, United Kingdom
  5. eImperial College Healthcare NHS Foundation Trust, Hammersmith Hospital, London, United Kingdom
  6. fSt. Thomas’ NHS Foundation Trust, Guys & St. Thomas Hospital, London, United Kingdom
  7. gKings College Hospital, King’s College Hospital NHS Foundation Trust, Denmark Hill, London, United Kingdom
  1. ↵∗Address for correspondence:
    Dr. Daniel A Jones, Department of Cardiology, Barts Heart Centre, St. Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, United Kingdom.

Abstract

Background A large proportion of patients presenting with non–ST-segment elevation myocardial infarction (NSTEMI) present with multivessel disease (MVD). There is uncertainty in the role of complete coronary revascularization in this group of patients.

Objectives The aim of this study was to investigate the outcomes of complete revascularization compared with culprit vessel–only intervention in a large contemporary cohort of patients undergoing percutaneous coronary intervention (PCI) for NSTEMI.

Methods The authors undertook an observational cohort study of 37,491 NSTEMI patients treated between 2005 and 2015 at the 8 heart attack centers in London. Clinical details were recorded at the time of the procedure into local databases using the British Cardiac Intervention Society (BCIS) PCI dataset. A total of 21,857 patients (58.3%) presented with NSTEMI and MVD. Primary outcome was all-cause mortality at a median follow-up of 4.1 years (interquartile range: 2.2 to 5.8 years).

Results A total of 11,737 (53.7%) patients underwent single-stage complete revascularization during PCI for NSTEMI, rates that significantly increased during the study period (p = 0.006). Those patients undergoing complete revascularization were older and more likely to be male, diabetic, have renal disease and a history of previous myocardial infarction/revascularization compared with the culprit-only revascularization group. Although crude, in-hospital major adverse cardiac event rates were similar (5.2% vs. 4.8%; p = 0.462) between the 2 groups. Kaplan-Meier analysis demonstrated significant differences in mortality rates between the 2 groups (22.5% complete revascularization vs. 25.9% culprit vessel intervention; p = 0.0005) during the follow-up period. After multivariate Cox analysis (hazard ratio: 0.90; 95% confidence interval: 0.85 to 0.97) and the use of propensity matching (hazard ratio: 0.89; 95% confidence interval: 0.76 to 0.98) complete revascularization was associated with reduced mortality.

Conclusions In NSTEMI patients with MVD, despite higher initial (in-hospital) mortality rates, single-stage complete coronary revascularization appears to be superior to culprit-only vessel PCI in terms of long-term mortality rates. This supports the need for further randomized study to confirm these findings.

Key Words

Multivessel disease (MVD) is encountered in 50% of non–ST-segment elevation myocardial infarction (NSTEMI) patients undergoing coronary angiography (1,2). In patients with ST-segment elevation myocardial infarction (STEMI) and MVD, recent randomized trials and meta-analyses (3–17) have demonstrated that multivessel revascularization is superior to culprit-only revascularization by reducing unplanned repeat revascularization (3,7–11,13,14,16), all-cause mortality (9), cardiac mortality (3,9,16), and repeat infarction (9,10,14). The benefits of complete revascularization in NSTEMI patients with MVD are unclear. Even though both the European Society of Cardiology and the American College of Cardiology guidelines recommend an early invasive strategy in high-risk patients (18,19), the extent of revascularization is not specified.

Studies have demonstrated that incomplete revascularization post-NSTEMI is associated with worse short- and long-term outcomes (20,21), and small studies have suggested prognostic benefit from complete revascularization in this patient group (22–28). However, there are still important unanswered issues including the timing of revascularization and truly whether complete revascularization is superior to culprit-only treatment in this patient group because a recent meta-analysis suggests no clear major adverse cardiac event (MACE) reduction or mortality benefit from complete revascularization despite surrogate suggestion of benefit seen (21). The main aim of the study was to analyze the frequency and long-term outcomes of complete revascularization compared with culprit vessel (CV) only in this large contemporary cohort of successive patients with MVD undergoing percutaneous coronary intervention (PCI) for NSTEMI.

Methods

This was an observational cohort study using a merged database from the 8 London heart attack centers who collect data based on the BCIS (British Cardiac Intervention Society) dataset.

Study database

The U.K. BCIS audit collects data from all hospitals in the United Kingdom that perform PCI, recording information about every procedure performed (29). The database is part of the suite of datasets collected under the auspices of the National Institute for Cardiovascular Outcomes Research and is compliant with U.K. data protection legislation. Data are collected prospectively at each hospital at the time of the procedure, electronically encrypted, and then transferred online to a central database. Each patient entry offers details of the patient journey, including the method and timing of admission, inpatient investigations, results, treatment, and outcomes. Patient clinical and demographic data, procedural characteristics, bleeding complications, procedural complications, all-cause in-hospital mortality, nonfatal myocardial infarction (MI), reintervention, and stroke are recorded during the admission. Patients’ survival data are obtained by linkage via the patients' National Health Service numbers to the Office of National Statistics, which records alive/death status and the date of death for all deceased patients.

Population study and design

We examined 37,491 consecutive patients with NSTEMI treated with PCI between January 2005 and May 2015 at all 8 tertiary cardiac centers in London, United Kingdom. There are no other centers in London that undertake PCI for acute coronary syndromes. Anonymous datasets with linked mortality data from the Office of National Statistics were merged for analysis from the 8 centers. Patients presenting in cardiogenic shock, patients with previous coronary artery bypass grafting, and non-CV chronic total occlusions defined as the presence of Thrombolysis In Myocardial Infarction (TIMI) flow grade 0 in a vessel not related to the acute infarct episode were excluded from the dataset. The study cohort consisted of 21,857 patients (58.3%) presenting with NSTEMI and MVD. A standard definition of MVD was used, defined as the presence of ≥75% luminal diameter stenosis in 2 or more major epicardial arteries (30). Patients were classified into CV intervention or complete revascularization groups (i.e., complete revascularization in the same setting). All patients with symptoms, electrocardiographic changes, as well as a rise in cardiac enzymes, which were consistent with NSTEMI were considered for PCI. Coronary angiography was performed via the radial or femoral artery. The culprit lesion was identified and crossed with an angioplasty guidewire. Manual thrombus aspiration was performed at the discretion of the operator followed by conventional PCI, usually with stenting, to the CV. Assessments with physiology and intravascular imaging was at the discretion of the operator.

Clinical outcomes

The primary clinical outcome was all-cause mortality at a median of 4.6 years (interquartile range: 2.2 to 6.2 years). Mortality data were obtained from the Office for National Statistics. In-hospital MACE were defined as death, MI (new pathological Q waves in the distribution of the treated coronary artery with an increase of creatine kinase-MB to ≥2 times the reference value or significant rise in troponin biomarkers), stroke, and repeat target vessel revascularization. Procedural complications recorded included MI, emergency coronary artery bypass grafting, arterial complications, aortic/coronary dissection, side branch occlusion, and arrhythmia. Following discharge, long-term all-cause mortality was obtained by linkage to the Office of National Statistics. Procedural success was defined as a CV with final TIMI flow grade 3 and residual stenosis <20% in the infarct-related artery at the end of the procedure.

Ethics

The data were collected as part of a mandatory national cardiac audit, and all patient-identifiable fields were removed before analysis. The local ethics committee advised us that formal ethical approval was not required.

Statistical analysis

Clinical characteristics of patients undergoing complete revascularization versus culprit-only treatment were compared using the Pearson chi square test for categorical variables and Student’s t-test for continuous variables. Normality of distribution was assessed using the Shapiro-Wilks test. We calculated Kaplan-Meier product limits for cumulative probability of reaching an endpoint and used the log-rank test for evidence of a statistically significant difference between the groups. In the case of missing data (except for left ventricular ejection fraction), unknown values were imputed to the most common categorical variable and to the median or subgroup-specific median of continuous variables. Time was measured from the index admission to outcome (all-cause mortality). Pre-specified landmark analyses were used to determine whether any difference in long-term outcomes was because of maintenance of short-term effects or additional effects beyond 6 months.

Cox regression analysis was used to estimate hazard ratios (HRs) for the effect of complete revascularization in age-adjusted and fully adjusted models, based on covariates (p < 0.05) associated with the outcome. A number of covariates were included in the model, including age, sex, diabetes, hypertension, hypercholesterolemia, previous PCI, previous MI, chronic renal failure, pre-procedure TIMI flow grade, year of study, procedural success, left main stem intervention, and glycoprotein (GP) IIb/IIIa use. The proportional hazards assumption was evaluated by examining log(−log) survival curves and additionally was tested with Schoenfeld's residuals. The proportional hazard assumption was satisfied for all outcomes evaluated. In addition, a sensitivity analysis was performed to evaluate the effect of including or excluding ejection fraction or previous PCI to the multivariate model.

A propensity score analysis was carried out using a nonparsimonious logistic regression model comparing CV intervention versus complete revascularization. Multiple variables were included in the model, including age, sex, diabetes, hypertension, hypercholesterolemia, previous PCI, previous MI, chronic renal failure, pre-procedure TIMI flow grade, procedural success, left main stem intervention, and GP IIb/IIIa use. After ranking the propensity score in an ascending order, a nearest neighbor 1:1 matching algorithm was used with calipers of 0.2 SDs of the logit of the propensity score. Each CV intervention and complete revascularization patient was used in at most 1 matched pair, to create a matched sample with similar distribution of baseline characteristics between observed groups. Based on the matched samples, the Cox proportional hazard model was used to determine the association of complete revascularization on mortality over follow-up. STATA version 14 (StataCorp, College Station, Texas) was used for all analyses.

Results

The study population consisted of 21,857 patients with a mean age of 67.3 years, and 74.3% were men; 58.0% of the patients had hypertension, 56.0% had dyslipidemia, 52.2% were active or exsmokers, and 29.8% had diabetes. The majority of PCI procedures were performed through the femoral route, accounting for 70.2% of procedures throughout the study period.

Of these patients, 11,737 (53.7%) underwent complete revascularization during their PCI (complete revascularization group) and 10,120 (46.3%) did not (CV group). The percentage of patients who had MVD increased over time, from 26.3% in 2005 to 35.9% in 2015 (Figure 1A) with an increase in rates of complete revascularization in patients with MVD and NSTEMI undergoing PCI (Figure 1B). The frequency of the use of complete revascularization varied across the different heart attack centers (range 38.1% to 79.2%) (Figure 2).

Figure 1
Figure 1

Demonstrating the Percentage of NSTEMI Patients With MVD and Rates of Complete Revascularization Over the Study Period

(A) Percentage of NSTEMI patients with multivessel disease undergoing PCI between 2005 and 2015 and (B) rates of complete revascularization within NSTEMI patients with MVD undergoing PCI between 2005 and 2015. MVD = multivessel disease; NSTEMI = non–ST-segment elevation myocardial infarction; PCI = percutaneous coronary intervention.

Figure 2
Figure 2

Showing the Rate of NSTEMI Patients According to PCI Center

Percentage of NSTEMI patients with MVD undergoing complete revascularization according to PCI center. PPCI = primary percutaneous coronary intervention; other abbreviations as in Figure 1.

Patient characteristics

Overall, those patients undergoing complete revascularization were older and more likely to be female, diabetic, have renal disease, a history of previous MI, and revascularization compared with the culprit-only revascularization group (Table 1). There were no differences in time from symptom onset or admission to revascularization between the groups.

View this table:
Table 1

Baseline Characteristics According to Complete Revascularization or Culprit Vessel Intervention Group

Procedural characteristics and outcomes

The complete revascularization group were more likely to have treatment via the femoral route, and receive a GP IIb/IIIa inhibitor during the procedure (Table 2). The radial access route was associated with lower mortality. The number of diseased vessels, mean number of vessels treated, and the vessel length was higher in the complete revascularization group. No difference in CV mean stent width or procedural success rates were seen between the 2 groups.

View this table:
Table 2

Procedural Characteristics According to Complete Revascularization or Culprit Vessel Intervention Group

In-hospital outcome

There were higher rates of death in the complete revascularization group, but lower rates of reintervention PCI. This probably explains why the unadjusted in-hospital MACE rates were similar in both groups (3.8% in the culprit group vs. 4.1% in the complete revascularization group; p = 0.462) (Table 3). Furthermore, there were higher rates of arterial complications in the complete revascularization group.

View this table:
Table 3

In-Hospital Outcomes and Complications Post-PCI According to Complete Revascularization or CV Intervention Group

Long-term outcome

Patients were followed up for a median of 4.6 years (interquartile range: 2.2 to 6.2 years). Kaplan-Meier analysis demonstrated that there was a statistically significant difference in mortality rates between the 2 groups (25.9% culprit-only group vs. 22.5% complete revascularization group; p = 0.0005) (Figure 3).

Figure 3
Figure 3

Survival Rates in Patients Over the Study Period

Kaplan-Meier curves showing cumulative probability of all-cause mortality after PCI according to group at 5 years (A), landmark analysis up to 6 months (B), from 6 months to 5 years (C), and Kaplan-Meier curves following propensity matching with 19,980 patients (D). LR = likelihood ratio; PCI = percutaneous coronary intervention.

Predictors of all-cause mortality

Age-adjusted Cox analysis (Table 4, Figure 4) revealed that complete revascularization was associated with reduced rates of all-cause mortality (HR: 0.86; 95% confidence intervals [CI]: 0.79 to 0.94). After multivariate adjustment (Figure 4), complete revascularization remained a predictor of survival (HR: 0.90; 95% CI: 0.85 to 0.97). This effect was the same when adjusted for ejection fraction (available for only 45% of patients) (HR: 0.84; 95% CI: 0.78 to 0.95) or PCI center (HR: 0.86; 95% CI: 0.80 to 0.94).

Figure 4
Figure 4

Multivariate Regression Analysis of All the Patients in the Study

Multivariate Cox regression analysis for hazard of all-cause mortality after percutaneous coronary intervention. CKD = chronic kidney disease; GP = glycoprotein; LMS = left main stem.

View this table:
Table 4

Cox Proportional Model of Univariate and Multivariate Analysis of Predictors of Mortality

Propensity matching

To further account for confounding variables and bias, propensity score matching was performed to adjust for differences in demographic and procedural variables, producing a total of 19,980 patients (9,900 in the complete revascularization group and 9,900 in the CV intervention group). Following matching, the baseline demographics and procedural variables were well balanced in the 2 propensity-matched cohorts. In the propensity-matched cohorts, Cox regression analysis revealed that complete revascularization during PCI for NSTEMI in patients with MVD was a predictor of reduced all-cause mortality (HR: 0.89; 95% CI: 0.76 to 0.98). This persisted even after including LV function in the propensity-matched scores (HR: 0.86; 95% CI: 0.65 to 0.96).

Landmark analyses

The Kaplan-Meier curves for 6-month and 5-year mortality for the unmatched cohort are shown in Figure 3. Higher mortality rates driven by the in-hospital events in the complete revascularization group are lost by 6 months with no difference seen between the groups (HR: 1.23; 95% CI: 0.74 to 3.22; p = 0.285). Applying the landmark method, during the period from 6 months to 5 years after treatment, patients undergoing complete revascularization had significantly reduced rates of all-cause mortality compared with culprit-only treatment (HR: 0.65; 95% CI: 0.35 to 0.82; p = 0.0005).

Discussion

This prospective, observational, multicenter registry analysis is the largest study to date investigating the impact of single-stage complete revascularization on long-term clinical outcomes in patients with NSTEMI and MVD. This analysis of outcomes from >21,000 patients provides convincing evidence that complete revascularization is associated with reduced long-term mortality compared with culprit-only revascularization (Central Illustration). This finding is despite an initial increased in-hospital mortality seen in the complete revascularization group, likely related to the higher risk and more complex nature of these patients. This suggests that operators were more likely to perform complete revascularization (operator bias) in the higher-risk patients with the benefits of revascularization over the long term seen with correction for these factors. Randomized study to investigate these effects is needed to see whether complete revascularization in this patient group is indeed indicated.

Central Illustration
Central Illustration

Complete Versus Culprit-Only Lesion Intervention in Patients With Acute Coronary Syndrome and Multivessel Disease: Survival Curves

Kaplan-Meier curves showing cumulative probability of all-cause mortality after percutaneous coronary intervention following propensity matching with 19,980 patients with multivessel disease and non–ST-segment elevation myocardial infarction.

Furthermore, the results from the landmark analyses indicate that the mortality benefit conferred by complete revascularization occurs beyond the first 6 months. The differences seen before 6 months are largely due to in-hospital mortality (2.3% in the complete revascularization group vs. 1.5% in the culprit-only group). Following 6 months, there is a benefit toward complete revascularization out to 5 years with the landmark analysis supporting this.

A recently published meta-analysis supports this fact with results very similar to our own suggesting complete revascularization in this patient group may improve outcomes (31). This review containing 4 randomized controlled trials of 838 patients suggested single-stage complete revascularization results in significantly decreased rates of unplanned repeat revascularization compared with staged multivessel PCI, with an association toward lower long-term risks of mortality and major adverse cardiovascular events; however, due to the small numbers, this was not adequately powered to show this. Our much larger-powered study adds to this evidence base, suggesting that single-stage complete revascularization is associated with improved mortality compared with culprit-only treatment.

A large body of accumulating data exists in STEMI supporting the role of complete revascularization in patients with MVD undergoing primary PCI. Rigorously performed randomized clinical trials have shown substantial benefit from complete revascularization (32–34), which have necessitated changes in recent guidelines (19). However, whether the results of the PRAMI (Preventive Angioplasty in Myocardial Infarction) (32), CvLPRIT (Complete Versus Lesion-Only Primary PCI) (33), and DANAMI-3-PRIMULTI (Primary PCI in Patients With ST-Elevation Myocardial Infarction and Multivessel Disease: Treatment of Culprit Lesion Only or Complete Revascularization) (34) trials can be extrapolated to NSTEMI is unclear. Consistent with the DANAMI-3-PRIMULTI trial (34), some investigators are of the opinion that a physiological assessment–guided revascularization approach would improve outcomes in patients with MVD undergoing PCI. In the FAME (Fractional Flow Reserve versus Angiography for Multivessel Evaluation) study, PCI guided by fractional flow reserve in patients with multivessel CAD demonstrated reduction in death or MI at 2 years when compared with standard angiography-guided PCI (35).

An important difference exists in angiographic findings in STEMI and NSTEMI with respect to determining the culprit artery; this tends to be obvious in STEMI, but in NSTEMI is not always possible. Culprit lesions should satisfy at least 2 of the criteria of intraluminal filling defect, plaque ulceration, plaque irregularity, dissection, or impaired flow (36–38), with approximately 40% of patients with NSTEMI and MVD having >1 plaque that fulfils these angiographic criteria (28,39), and 25% of these have 1 artery that is completely occluded, which in most patients is collateralized (38,40). There are methods to establish the culprit lesion over and above angiography (19), including territorial ST-segment changes on the electrocardiogram, segmental hypokinesia on echocardiography or ventriculography, provocative testing (e.g., acetylcholine), or with optical coherence tomography (41–43). This may explain some of the benefit of complete revascularization in this study, with this strategy ensuring treatment of the CV compared with single-vessel treatment where the second potential culprit may be left untreated if not obvious, with the benefit of revascularization versus medical treatment well established (44–46).

The important issue of the timing of complete revascularization was not addressed in this study. Staged complete revascularization, either during the index hospitalization or soon after hospital discharge, has been recommended as a means of preventive revascularization that may avoid many of the drawbacks of multivessel intervention during the index procedure. Unfortunately, the intent for staged intervention at the time of the index PCI was not captured in this dataset, and this could be deemed as a limitation to the study although excluding patients intended for staged PCI who may have died before the staged procedure introduces a survival bias. The timing of the staged procedure also varies across operators and different practices, even within London; although some consider 2 to 4 weeks as an appropriate waiting period, reimbursement considerations and potential penalties for readmission often prolong this window beyond 30 days (47). Importantly the recent SMILE (Impact of Different Treatment in Multivessel Non ST Elevation Myocardial Infarction [NSTEMI] Patients) trial (48) enrolled 542 patients with NSTEMI and MVD randomizing in a 1:1 fashion to complete revascularization during a single procedure or to culprit-only revascularization, followed by revascularization of the remaining lesions at a later date. There were significantly lower rates of the major adverse cardiovascular and cerebrovascular events in the 1-stage complete revascularization at 1-year follow-up. This difference was entirely caused by a higher rate of target vessel revascularization in the multistage group with no differences in terms of hard clinical endpoints, such as death or MI, between the 2 groups. This does support the concept that if complete revascularization is to be performed, it should be done in 1 complete procedure, supporting our study’s results.

Study strengths and limitations

The strength of this study is that it includes patients from 8 different centers in a large metropolitan city with a diverse ethnic and social make-up. The study includes patients with a number of comorbidities and is thus representative of the broad range of patients encountered in day-to-day clinical practice. Although inclusion of such patients may result in some baseline differences between the groups, differences were mitigated by use of multivariate analyses and propensity analyses. Mortality tracking in England is particularly robust based on official U.K. Office of National Statistics data, and hence our mortality endpoint is reliable. The multivariate analyses are also reassuring because they confirm that well-recognized predictors of mortality were associated with adverse outcomes in our dataset.

However, our study has limitations. First, our study only applies to patients with NSTEMI who underwent PCI and does exclude patients with non-culprit chronic total occlusion lesions and cardiogenic shock, which can limit the generalizability of the results. Importantly, this study has all the limitations of a registry and with all the potential bias and unmeasured confounding associated with nonrandomized analyses. In addition, our study does not address the issue of whether complete revascularization needs to be performed at 1 sitting or as a staged procedure (i.e., 4 to 6 weeks after index presentation), and therefore, timing of complete revascularization remains an important limitation of the paper. Finally, because the study started in 2005, there has been significant changes in contemporary practice with an increase in the use of fractional flow reserve, intravascular ultrasound, optical coherence tomography, and drug-eluting stent implantation, all factors that should be taken into account for future studies.

Conclusions

In NSTEMI patients with MVD, single-stage complete coronary revascularization appears to be superior to culprit-only vessel PCI in terms of long-term mortality rates. This observation needs to be validated with a larger randomized controlled trial that is powered to hard clinical endpoints.

Perspectives

COMPETENCY IN PATIENT CARE AND PROCEDURAL SKILLS: Single-stage, complete multivessel percutaneous revascularization is associated with better long-term survival than culprit vessel–only revascularization in patients with NSTEMI, as previously found for patients with STEMI.

TRANSLATIONAL OUTLOOK: Further research is required to establish whether the timing of complete revascularization (i.e., single stage vs. multistage and the interval between procedures) is important in improving outcomes in patients with NSTEMI and multivessel disease undergoing PCI.

Footnotes

  • Dr. Dalby has received research grants from Abbott Vascular, Daiichi-Sankyo/Lily, and Sanofi; and has been a consultant for AstraZeneca, Eli Lilly, Medtronic, Edwards Lifesciences, and Boston Scientific. Dr. Smith has received speakers fees/honoraria from Boston Scientific, Abbott Vascular, Vascular Perspectives, and Biosensors International. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

  • Listen to this manuscript's audio summary by JACC Editor-in-Chief Dr. Valentin Fuster.

Abbreviations and Acronyms
CI
confidence interval
CV
culprit vessel
GP
glycoprotein
HR
hazard ratio
MACE
major adverse cardiac events
MI
myocardial infarction
MVD
multivessel disease
NSTEMI
non–ST-segment elevation myocardial infarction
PCI
percutaneous coronary intervention
STEMI
ST-segment elevation myocardial infarction
TIMI
Thrombolysis In Myocardial Infarction
  • Received March 20, 2018.
  • Revision received June 29, 2018.
  • Accepted July 30, 2018.

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