Introduction The optimal revascularisation strategy for patients presenting with ST-Segment Elevation MI (STEMI) and multivessel coronary disease remains under debate. Although current practice in patients without cardiogenic shock is to treat the infarct-related artery only at the time of presentation, it is not clear whether residual coronary disease should be treated either during the acute admission or post-discharge.
Methods All Patients presenting to UHL between April 2008 and November 2011 with STEMI undergoing Primary PCI were analysed retrospectively. The outcome measure was mortality either in-hospital or post-discharge. All patients were followed-up until end of November 2011, follow-up duration is expressed as mean±SD. Patients were divided into three groups; PCI for single vessel disease (SVD), Multivessel disease (MVD) & single vessel PCI and MVD & multivessel PCI. Baseline characteristics (age, gender, risk factors, TIMI flow pre- and post-procedure, smoking history, cardiogenic shock, previous MI, CABG or PCI) were compared between groups. Statistical comparison was made using χ2 test for categorical data and t test for continuous data.
Results 829 patients underwent Primary PCI between April 2008 and November 2011. 530 had single vessel disease. 299 patients had MVD; 193 underwent single vessel angioplasty to the infarct related artery, 71 patients underwent multivessel PCI at time of primary PCI and 35 had a further PCI either during that admission or post-discharge. Mean follow-up was 524±347 days. Overall in-hospital mortality was 3.5% and mortality to follow-up was 8.5%. Baseline characteristics were similar between groups with the exception of previous MI and Previous CABG which was significantly higher among patients with MVD & single vessel PCI. Cardiogenic shock was also higher among patients with MVD & multivessel PCI (19% vs SVD 3.8%, p<0.05). In-hospital mortality between the three groups was similar; SVD=3%, MVD& single vessel PCI=4.9%, MVD & multivessel PCI=2.9%, p=0.203. Overall mortality to follow-up between the three groups was also similar (Abstract 131 table 1, p=0.20). Exclusion of cardiogenic shock demonstrated a trend towards improved overall mortality in patients undergoing multivessel PCI (Abstract 131 table 2, p=0.17). Looking exclusively at patients post-discharge, a similar trend towards improved mortality with multivessel PCI was seen (SVD=5.1%, MVD with single vessel PCI=4.97%, MVD disease with multivessel PCI=1.94%; p=0.372).
Conclusions These findings show a trend towards lower mortality post-discharge with mutlivessel PCI carried out in STEMI patients with MVD, suggesting consideration should be given to complete revascularisation in haemodynamically stable STEMI patients with multivessel disease, either during acute admission or post-discharge. The results of the ongoing UK multicentre randomised trial CVLPRIT will address this important aspect of managing patients with STEMI and multivessel disease.
- Multivessel disease
- primary PCI
- revascularisation strategy