PCI for STEMI should be limited to infarct related coronary arteries

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NEW YORK (From Reuters Health) – Performing percutaneous coronary interventions (PCI) in non-infarct-related coronary vessels along with primary PCI for ST-segment elevation myocardial infarction (STEMI) appears to jeopardize patient survival, Canadian researchers reported online June 8 in the European Heart Journal.

Despite guidelines to the contrary, some 10% of STEMI patients with multi-vessel coronary artery disease had non-culprit coronary interventions during primary PCI, the researchers found.

“Although our non-randomized analysis cannot conclusively demonstrate a causal relationship, the data strongly support current guideline recommendations discouraging non-infarct-related artery PCI procedures performed at the time of primary PCI when patients are haemodynamically stable.”

Dr. Paul W. Armstrong, of the University of Alberta in Edmonton, and colleagues analyzed data from the earlier APEX-AMI trial, which took place in several centers around the world. Among the 5373 patients who underwent primary PCI, 2201 (41%) had multivessel coronary artery disease.

Patients with single-vessel disease only underwent culprit-artery PCI, and had lower 90-day mortality than patients with multivessel disease (3.1% vs. 6.3%, p<0.001).

Most of the patients with multivessel disease had PCI only in the lesioned artery (90.1%), while 217 (9.9%) received additional PCI in a non-culprit coronary artery. Non-culprit artery PCI was more common in North America (12.6%) and Western Europe (10.5%) than in Eastern Europe (6.6%) and Australia/New Zealand (6.1%) (p=0.001).

In an e-mail to Reuters Health, Dr. Armstrong said the geographic variation was probably related to the “more ‘aggressive’ interventional environment where fee for services and procedures may influence behaviors” in Western countries.

The push to get patients out of the hospital faster and avoid a second procedure might also be involved, added Dr. Armstrong.

There was no difference in the length of hospital stay between those patients who had the extra intervention and those who didn’t. However, the 90-day mortality was higher in the former group than the latter (12.5% vs. 5.6%, p<0.001), as was the composite endpoint of death, congestive heart failure, and cardiogenic shock (18.9% vs. 13.1%, p<0.011).

After adjusting for patient and procedural characteristics, 90-day mortality remained higher with non-culprit artery PCI (hazard ratio, 2.44, p<0.001), while differences in the composite endpoint lost statistical significance.

The researchers could not rule out that the additional procedures were caused by transient hemodynamic instability — and were thus in agreement with guidelines — but the geographical trends would suggest otherwise, they say.

“The current guidelines in place are sensible and should be followed except under very extenuating circumstances,” Dr. Armstrong said. “Less may be more” for STEMI patients, he concluded.

(From: Non-culprit coronary artery percutaneous coronary intervention during acute ST-segment elevation myocardial infarction: insights from the APEX-AMI trial, Mustafa Toma et al. for the APEX-AMI InvestigatorsEuropean Heart Journal (2010) 31, 1701–1707)

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