M Bilal Iqbal1, Charles Ilsley2, Tito Kabir2, Robert Smith2, Rebecca Lane2, Mark Mason2, Piers Clifford2, Tom Crake2, Sam Firoozi2, Sundeep Kalra2, Charles Knight2, Pitt Lim2, Iqbal S Malik2, Anthony Mathur2, Pascal Meier2, Roby D Rakhit2, Simon Redwood2, Mark Whitbread2, Dan Bromage2, Krishna Rathod2, Philip MacCarthy2, Miles Dalby2. 1. From the Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Middlesex, United Kingdom (M.B.I., C.I., T.K., R.S., R.L., M.M., P.C., M.D.); Department of Cardiology, UCL Hospitals NHS Foundation Trust, Heart Hospital, London, United Kingdom (T.C., P. Meier); Department of Cardiology, King's College Hospital NHS Foundation Trust, London, United Kingdom (S.K., P. MacCarthy); Department of Cardiology, Barts Health NHS Trust, The London Chest Hospital, London, United Kingdom (C.K., A.M., D.B., K.R.); Department of Cardiology, St. George's Healthcare NHS Foundation Trust, St. George's Hospital, London, United Kingdom (S.F., P.L.); Department of Cardiology, Imperial College Healthcare NHS Foundation Trust, Hammersmith Hospital, London, United Kingdom (I.S.M.); Department of Cardiology, Royal Free London NHS Foundation Trust, London, United Kingdom (R.D.R.); Department of Cardiology, BHF Centre of Excellence, King's College London, St. Thomas Hospital, London, United Kingdom (S.R.); and Department of Cardiology, London Ambulance Service, London, United Kingdom (M.W.). b.iqbal@imperial.ac.uk. 2. From the Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Middlesex, United Kingdom (M.B.I., C.I., T.K., R.S., R.L., M.M., P.C., M.D.); Department of Cardiology, UCL Hospitals NHS Foundation Trust, Heart Hospital, London, United Kingdom (T.C., P. Meier); Department of Cardiology, King's College Hospital NHS Foundation Trust, London, United Kingdom (S.K., P. MacCarthy); Department of Cardiology, Barts Health NHS Trust, The London Chest Hospital, London, United Kingdom (C.K., A.M., D.B., K.R.); Department of Cardiology, St. George's Healthcare NHS Foundation Trust, St. George's Hospital, London, United Kingdom (S.F., P.L.); Department of Cardiology, Imperial College Healthcare NHS Foundation Trust, Hammersmith Hospital, London, United Kingdom (I.S.M.); Department of Cardiology, Royal Free London NHS Foundation Trust, London, United Kingdom (R.D.R.); Department of Cardiology, BHF Centre of Excellence, King's College London, St. Thomas Hospital, London, United Kingdom (S.R.); and Department of Cardiology, London Ambulance Service, London, United Kingdom (M.W.).
Abstract
BACKGROUND: It is estimated that up to two thirds of patients presenting with ST-segment-elevation myocardial infarction have multivessel disease. The optimal strategy for treating nonculprit disease is currently under debate. This study provides a real-world analysis comparing a strategy of culprit-vessel intervention (CVI) versus multivessel intervention at the time of primary percutaneous coronary intervention in patients with ST-segment-elevation myocardial infarction. METHODS AND RESULTS: We compared CVI versus multivessel intervention in 3984 patients with multivessel disease undergoing primary percutaneous coronary intervention between 2004 and 2011 at all 8 tertiary cardiac centers in London. Multivariable-adjusted models were built to determine independent predictors for in-hospital major adverse cardiovascular events (MACEs) and all-cause mortality at 1 year. To reduce confounding and bias, propensity score methods were used. CVI was associated with reduced in-hospital MACE (4.6% versus 7.2%; P=0.010) and mortality at 1 year (7.4% versus 10.1%; P=0.031). CVI was an independent predictor for reduced in-hospital MACE (odds ratio, 0.49; 95% confidence interval [CI], 0.32-0.75; P<0.001) and survival at 1 year (hazard ratio, 0.65; 95% CI, 0.47-0.91; P=0.011) in the complete cohort; and in 2821 patients in propensity-matched cohort (in-hospital MACE: odds ratio, 0.49; 95% CI, 0.32-0.76; P=0.002; and 1-year survival: hazard ratio, 0.64; 95% CI, 0.45-0.90; P=0.010). Inverse probability treatment weighted analyses also confirmed CVI as an independent predictor for reduced in-hospital MACE (odds ratio, 0.38; 95% CI, 0.15-0.96; P=0.040) and survival at 1 year (hazard ratio, 0.44; 95% CI, 0.21-0.93; P=0.033). CONCLUSIONS: In this observational analysis of patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention, CVI was associated with increased survival at 1 year. Acknowledging the limitations with observational analyses, our findings support current recommended practice guidelines.
RCT Entities:
BACKGROUND: It is estimated that up to two thirds of patients presenting with ST-segment-elevation myocardial infarction have multivessel disease. The optimal strategy for treating nonculprit disease is currently under debate. This study provides a real-world analysis comparing a strategy of culprit-vessel intervention (CVI) versus multivessel intervention at the time of primary percutaneous coronary intervention in patients with ST-segment-elevation myocardial infarction. METHODS AND RESULTS: We compared CVI versus multivessel intervention in 3984 patients with multivessel disease undergoing primary percutaneous coronary intervention between 2004 and 2011 at all 8 tertiary cardiac centers in London. Multivariable-adjusted models were built to determine independent predictors for in-hospital major adverse cardiovascular events (MACEs) and all-cause mortality at 1 year. To reduce confounding and bias, propensity score methods were used. CVI was associated with reduced in-hospital MACE (4.6% versus 7.2%; P=0.010) and mortality at 1 year (7.4% versus 10.1%; P=0.031). CVI was an independent predictor for reduced in-hospital MACE (odds ratio, 0.49; 95% confidence interval [CI], 0.32-0.75; P<0.001) and survival at 1 year (hazard ratio, 0.65; 95% CI, 0.47-0.91; P=0.011) in the complete cohort; and in 2821 patients in propensity-matched cohort (in-hospital MACE: odds ratio, 0.49; 95% CI, 0.32-0.76; P=0.002; and 1-year survival: hazard ratio, 0.64; 95% CI, 0.45-0.90; P=0.010). Inverse probability treatment weighted analyses also confirmed CVI as an independent predictor for reduced in-hospital MACE (odds ratio, 0.38; 95% CI, 0.15-0.96; P=0.040) and survival at 1 year (hazard ratio, 0.44; 95% CI, 0.21-0.93; P=0.033). CONCLUSIONS: In this observational analysis of patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention, CVI was associated with increased survival at 1 year. Acknowledging the limitations with observational analyses, our findings support current recommended practice guidelines.
Authors: S Ghauharali-Imami; M Bax; A Haasdijk; C Schotborgh; P Oemrawsingh; J Bech; R van Domburg; F Zijlstra Journal: Neth Heart J Date: 2015-12 Impact factor: 2.380