Limiting treatment to “culprit lesions” remains the preferred choice of clinicians treating hemodynamically stable ST-elevation MI (STEMI) patients who have evidence of multivessel disease on angiography, according to analysis of a decade of data collected by a national registry.
Even after positive results from the COMPLETE randomized trial demonstrated the superiority of multivessel (MV) PCI over culprit-only PCI, only a minority of eligible patients (37.9%) undergo MV PCI, wrote Eric A. Secemsky, MD of the Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School in Boston, and colleagues in JAMA Cardiology.
And that is good news, according to John A. Bittl, MD, of the Interventional Cardiology Group at AdventHealth in Ocala, Florida. In an invited commentary, Bittl was blunt in his assessment of the push for MV PCI.
“Clinicians have been forced to wade through a morass of conflicting reports and a slew of contradictory guidelines that have gone around in circles and still not reached a consensus about the timing of multivessel PCI or provided a consistent recommendation for patients with or without cardiogenic shock,” Bittl wrote. “As with old English equity law, the clinical investigation of multivessel PCI has thrived on contradictory findings that produce little change in practice and, despite all good intentions, has only benefited the experts who need to keep publishing. Secemsky and colleagues should be commended for showing that culprit-only PCI is the preferred approach in practice and routine multivessel PCI is unpropitious. The findings indicate that clinicians have not replaced common sense with the ’uncertain, unsettled and confused’ state of the evidence.”
Secemsky and colleagues looked at 359,879 STEMI admissions of patients with MV disease at 1,598 institutions that participate in the National Cardiovascular Data Registry CathPCI Registry over roughly a 9-year period from the third quarter of 2009 through the first quarter of 2018.
Among the findings:
- MV PCI was performed in 38.5% (n = 138,380).
- The mean age of MV PCI patients was 62.3 and 73.9% were men.
- 30.8% (n = 42,629) had an MC PCI during the index procedure.
- 31.6% (n = 43,696) as a staged procedure during the index hospitalization.
- 37.6% (n = 52,055) within 45 days of discharge.
“Complete revascularization of all diseased arteries was performed in 76.2% (n = 105,389). From the third quarter of 2009 to the second quarter of 2013, MV PCI use declined by 10%, from 42.7% (3,230 of 7,572 cases) to a nadir of 32.7% (3,386 of 10,342 cases), followed by an increase to 44.0% (5062 of 11,497 cases) by the fourth quarter of 2017. During this time, there was a 13.6% decline in use of post discharge staged MV PCI (from 23.4% of STEMI cases [1,772 of 7,572 cases] in the third quarter of 2009 to 9.9% [1,094 of 11,171 cases] in the fourth quarter of 2014) and an 12.5% increase in MV PCI performed during the index admission (from 19.3% [1,458 of 7,572 cases] in the third quarter of 2009 to 31.8% [3,557 of 11,171 cases] in the first quarter of 2018). Multivessel PCI use varied substantially across institutions, with a median use of 37.9% (interquartile range, 30.0%-46.5%),” Secemsky et al reported.
Bittl took issue with the researchers’ observation that “[C]hanges in clinical practice appeared to coincide with emerging evidence surrounding MV PCI for STEMI,” noting that “in reality, the response has been modest at best. The absolute difference of 11 percentage points between the nadir and the peak means that the use of multivessel PCI changed in only 1 of 9 patients. This is not exactly high uptake, which probably reflects the belief throughout all periods that culprit-only PCI is the default strategy, with preemptive PCI on nonculprit vessels being reserved for special circumstances.”
And, in fact, Secemsky and colleagues acknowledged that the “observed variation in use of MV PCI across U.S. institutions suggests that operators interpret and respond to evidence differently.”
If the goal is to have clinicians really practice evidence-based medicine, then guideline writers will need to respond by make guideline changes “timely” rather than waiting months or years between published evidence and guideline updates.
Their study was not without limitations, and Secemsky et al pointed out that they relied on self-reported data, which may “be subject to misclassification.”
The use of multivessel PCI increased over the decade form 2009 through 2018 so that it was used in 44% of PCI procedures in STEMI patients with multivessel disease.
Despite the increase in use of MV PCI, it is still used in the minority of patients with ST-elevation myocardial infarction and MV disease, with substantial heterogeneity across institutions in the U.S.
Peggy Peck, Editor-in-Chief, BreakingMED™
Secemsky reported grants and personal fees from Cook, BD, Medtronic, Philips, and CSI; grants from Boston Scientific and AstraZeneca; and personal fees from Janssen and Abbott Vascular outside the submitted work.
Bittl had no disclosures.
Cat ID: 306
Topic ID: 74,306,306,358,192,925