What is optimal revascularization strategy in patients with multivessel coronary artery disease in non-ST-elevation myocardial infarction? Multivessel or culprit-only revascularization.
BACKGROUND
In patients with non-ST-elevation myocardial infarction (NSTEMI), current guidelines did not recommend optimal revascularization management in multivessel coronary artery disease. We compared clinical outcomes between multivessel revascularization and culprit-only revascularization in this setting.


METHODS
A total of 1919 patients with multivessel disease (1011 patients; multivessel revascularization group, 908 patients; culprit-only revascularization group) diagnosed as NSTEMI was enrolled in a nationwide prospective Korea Acute Myocardial Infarction Registry (KAMIR) from November 2005 to January 2008. The primary end-points were major adverse cardiac events (MACE), all-causes of deaths, myocardial infarction (MI), and repeated percutaneous coronary intervention (PCI) during 1-year clinical follow-up. Also, subgroup analysis was performed in patients with high TIMI (Thrombolysis In Myocardial Infarction) risk score (≥ 4) to find efficacy of multivessel PCI in high-risk patients.


RESULTS
Baseline clinical characteristics and the risk factors of coronary artery disease were similar between both groups. In angiography, three-vessel lesion was more presented in the multivessel group (46.1% vs. 40.9%, p = 0.024) and rates of left anterior descending and left main stem coronary artery as culprit vessel were higher in the multivessel group (p = 0.003 and p = 0.001 respectively). In-hospital mortality was higher in the culprit-only group (1.4% vs. 2.9%, p = 0.025). Primary end-points occurred in 241 patients (15.5%) during 1-year follow-up. Multivessel revascularization reduced MACEs [hazard ratio (HR) 0.658, 95% confidence interval (CI) 0.45 to 0.96, p = 0.031], death or myocardial infarction (HR 0.58, 95% CI 0.35 to 0.97, p = 0.037) and non-target vessel revascularization (HR 0.44, 95% CI 0.24 to 0.81, p = 0.008). There were no significant differences in target lesion revascularization (TLR; HR 1.38, 95% CI 0.51 to 3.71, p = 0.529) and target vessel revascularization (TVR; HR 0.28, 95% CI 0.05 to 1.47, p = 0.131). In subgroup analysis in patients with a higher TIMI risk score, similar results were presented.


CONCLUSIONS
Multivessel revascularization in multivessel coronary artery disease presenting with NSTEMI showed better clinical outcomes without significant in-stent restenosis and progression of diseased-vessel compared to culprit-only revascularization.
Kim
Min Chul
MC
Chonnam National University Hospital, South Korea.
Jeong
Myung Ho
MH
Ahn
Youngkeun
Y
Kim
Jong Hyun
JH
Chae
Shung Chull
SC
Kim
Young Jo
YJ
Hur
Seung Ho
SH
Seong
In Whan
IW
Hong
Taek Jong
TJ
Choi
Dong Hoon
DH
Cho
Myeong Chan
MC
Kim
Chong Jin
CJ
Seung
Ki Bae
KB
Chung
Wook Sung
WS
Jang
Yang Soo
YS
Cho
Seung Yun
SY
Rha
Seung Woon
SW
Bae
Jang Ho
JH
Cho
Jeong Gwan
JG
Park
Seung Jung
SJ
D000368:Aged; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000401:mortality* / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000000981:diagnostic imaging / Q000401:mortality* / Q000601:surgery*; D009204:Myocardial Revascularization / Q000379:methods*; D011446:Prospective Studies; D011859:Radiography; D012042:Registries