title: Prognostic impact of staged versus "one-time" multivessel percutaneous intervention in acute myocardial infarction: analysis from the HORIZONS-AMI (harmonizing outcomes with revascularization and stents in acute myocardial infarction) trial.
abstract: OBJECTIVE
  The purpose of this study was to compare a one-time primary percutaneous coronary intervention (PCI) of the culprit and nonculprit lesions with PCI of only the culprit lesion and staged nonculprit PCI at a later date in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease.
  
  
  BACKGROUND
  In patients with STEMI and multivessel disease, it is unknown whether it is safe or even desirable to also treat the nonculprit vessel during the primary PCI procedure.
  
  
  METHODS
  In the HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) trial, 668 of the 3,602 STEMI patients enrolled (18.5%) underwent PCI of culprit and nonculprit lesions for multivessel disease. Patients were categorized into a single PCI strategy (n = 275) versus staged PCI (n = 393). The endpoints analyzed included the 1-year rates of major adverse cardiovascular events and its components, death, reinfarction, target-vessel revascularization for ischemia, and stroke.
  
  
  RESULTS
  Single versus staged PCI was associated with higher 1-year mortality (9.2% vs. 2.3%; hazard ratio [HR]: 4.1, 95% confidence interval [CI]: 1.93 to 8.86, p < 0.0001), cardiac mortality (6.2% vs. 2.0%; HR: 3.14, 95% CI: 1.35 to 7.27, p = 0.005), definite/probable stent thrombosis (5.7% vs. 2.3%; HR: 2.49, 95% CI: 1.09 to 5.70, p = 0.02), and a trend toward greater major adverse cardiovascular events (18.1% vs. 13.4%; HR: 1.42, 95% CI: 0.96 to 2.1, p = 0.08). The mortality advantage favoring staged PCI was maintained in a subgroup of patients undergoing truly elective multivessel PCI. Also, the staged PCI strategy was independently associated with lower all-cause mortality at 30 days and at 1 year.
  
  
  CONCLUSIONS
  A deferred angioplasty strategy of nonculprit lesions should remain the standard approach in patients with STEMI undergoing primary PCI, as multivessel PCI may be associated with a greater hazard for mortality and stent thrombosis. (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction [HORIZONS-AMI]; NCT00433966).
authors.affiliation: Rabin Medical Center, Petach Tikva, Israel, and Tel Aviv University, Tel Aviv, Israel. ran.kornowski@gmail.com
authors.forename: Ran
authors.initials: R
authors.lastname: Kornowski
authors.forename: Roxana
authors.initials: R
authors.lastname: Mehran
authors.forename: George
authors.initials: G
authors.lastname: Dangas
authors.forename: Eugenia
authors.initials: E
authors.lastname: Nikolsky
authors.forename: Abid
authors.initials: A
authors.lastname: Assali
authors.forename: Bimmer E
authors.initials: BE
authors.lastname: Claessen
authors.forename: Bernard J
authors.initials: BJ
authors.lastname: Gersh
authors.forename: S Chiu
authors.initials: SC
authors.lastname: Wong
authors.forename: Bernhard
authors.initials: B
authors.lastname: Witzenbichler
authors.forename: Giulio
authors.initials: G
authors.lastname: Guagliumi
authors.forename: Dariusz
authors.initials: D
authors.lastname: Dudek
authors.forename: Martin
authors.initials: M
authors.lastname: Fahy
authors.forename: Alexandra J
authors.initials: AJ
authors.lastname: Lansky
authors.forename: Gregg W
authors.initials: GW
authors.lastname: Stone
mesh_terms: D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects; D003324:Coronary Artery Disease / Q000473:pathology / Q000628:therapy; D003331:Coronary Vessels / Q000473:pathology; D004562:Electrocardiography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015337:Multicenter Studies as Topic; D009203:Myocardial Infarction / Q000503:physiopathology / Q000628:therapy*; D011379:Prognosis; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D015607:Stents; D015912:Thrombolytic Therapy