Journal of the American College of Cardiology
Complete Versus Culprit-Only Lesion Intervention in Patients With Acute Coronary Syndromes
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Author + information
- Krishnaraj S. Rathod, MDa,
- Sudheer Koganti, MDa,
- Ajay K. Jain, MDa,
- Zoe Astroulakis, MD, PhDb,
- Pitt Lim, MDb,
- Roby Rakhit, MDc,
- Sundeep Singh Kalra, MDc,
- Miles C. Dalby, MDd,
- Constantinos O’Mahony, MDa,
- Iqbal S. Malik, MDe,
- Charles J. Knight, MDa,
- Anthony Mathur, MD, PhDa,
- Simon Redwood, MDf,
- Alexander Sirker, MD, PhDa,
- Philip A. MacCarthy, MD, PhDg,
- Elliot J. Smith, MDa,
- Andrew Wragg, MD, PhDa and
- Daniel A. Jones, MD, PhDa,∗ (daniel.jones{at}qmul.ac.uk), @bhcintervention@BartsIntervGrp
- aBarts Health NHS Trust, London, United Kingdom
- bSt. George’s Healthcare NHS Foundation Trust, St. George’s Hospital, London, United Kingdom
- cRoyal Free London NHS Foundation Trust, London, United Kingdom
- dRoyal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, Middlesex, London, United Kingdom
- eImperial College Healthcare NHS Foundation Trust, Hammersmith Hospital, London, United Kingdom
- fSt. Thomas’ NHS Foundation Trust, Guys & St. Thomas Hospital, London, United Kingdom
- gKings College Hospital, King’s College Hospital NHS Foundation Trust, Denmark Hill, London, United Kingdom
- ↵∗Address for correspondence:
Dr. Daniel A Jones, Department of Cardiology, Barts Heart Centre, St. Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, United Kingdom.
Central Illustration
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.
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.
- Received March 20, 2018.
- Revision received June 29, 2018.
- Accepted July 30, 2018.
- 2018 American College of Cardiology Foundation
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