title: Culprit Vessel Versus Multivessel Versus In-Hospital Staged Intervention for Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Disease: Stratified Analyses in High-Risk Patient Groups and Anatomic Subsets of Nonculprit Disease.
abstract: This study evaluated revascularization strategies for patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease.
  
  
  
  In patients with STEMI and multivessel disease, it is unclear whether multivessel intervention (MVI), culprit vessel intervention (CVI) only (CVI-O) or CVI with staged revascularization (CVI-S) is associated with improved outcomes. Whether MVI at primary percutaneous coronary intervention may benefit specific patient groups is unclear.
  
  
  
  We compared revascularization strategies (MVI, CVI-O, and CVI-S) in 6,503 patients with STEMI and multivessel disease enrolled in the British Columbia Cardiac Registry (2008 to 2014). We evaluated all-cause mortality and repeat revascularization at 2 years.
  
  
  
  Compared with MVI, CVI-O (hazard ratio [HR]: 0.78; 95% confidence interval [CI]: 0.64 to 0.97; p = 0.023) and CVI-S (HR: 0.55; 95% CI: 0.36 to 0.82; p = 0.004) were associated with lower mortality. Comparing CVI-O with CVI-S, CVI-S was associated with lower mortality (HR: 0.65; 95% CI: 0.47 to 0.91; p = 0.013). Compared with MVI, CVI-O was associated with increased repeat revascularization (HR: 1.25; 95% CI: 1.02 to 1.54; p = 0.036). Comparing CVI-O versus CVI-S, CVI-S was associated with lower repeat revascularization (HR: 0.64; 95% CI: 0.46 to 0.90; p = 0.012). CVI was associated with lower mortality in the presence of nonculprit left circumflex artery disease (HR: 0.63; 95% CI: 0.45 to 0.89; p = 0.011) and right coronary artery disease (HR: 0.66; 95% CI: 0.44 to 0.99; p = 0.050), but not nonculprit left anterior descending artery disease (HR: 0.83; 95% CI: 0.54 to 1.28; p = 0.399).
  
  
  
  In patients with STEMI undergoing primary percutaneous coronary intervention, a strategy of CVI-S seems to be associated with lower mortality and repeat revascularization rates. However, MVI may be considered in selected patients and in the setting of nonculprit left anterior descending artery disease. These findings warrant prospective evaluation in large adequately powered randomized controlled trials.
authors.affiliation: Victoria Heart Institute Foundation, British Columbia, Canada; Royal Jubilee Hospital, British Columbia, Canada. Electronic address: biqbal@excite.com.
authors.forename: M Bilal
authors.initials: MB
authors.lastname: Iqbal
authors.affiliation: Victoria Heart Institute Foundation, British Columbia, Canada; Royal Jubilee Hospital, British Columbia, Canada.
authors.forename: Imad J
authors.initials: IJ
authors.lastname: Nadra
authors.affiliation: Provincial Health Services Authority, British Columbia, Canada.
authors.forename: Lillian
authors.initials: L
authors.lastname: Ding
authors.affiliation: Vancouver General Hospital, British Columbia, Canada.
authors.forename: Anthony
authors.initials: A
authors.lastname: Fung
authors.affiliation: St. Paul's Hospital, British Columbia, Canada.
authors.forename: Eve
authors.initials: E
authors.lastname: Aymong
authors.affiliation: Royal Columbian Hospital, British Columbia, Canada.
authors.forename: Albert W
authors.initials: AW
authors.lastname: Chan
authors.affiliation: Kelowna General Hospital, Kelowna, British Columbia, Canada.
authors.forename: Steven
authors.initials: S
authors.lastname: Hodge
authors.affiliation: Victoria Heart Institute Foundation, British Columbia, Canada; Royal Jubilee Hospital, British Columbia, Canada.
authors.forename: Anthony
authors.initials: A
authors.lastname: Della Siega
authors.affiliation: Victoria Heart Institute Foundation, British Columbia, Canada; Royal Jubilee Hospital, British Columbia, Canada.
authors.forename: Simon D
authors.initials: SD
authors.lastname: Robinson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001955:British Columbia; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D057216:Propensity Score; D016016:Proportional Hazards Models; D012042:Registries; D019233:Retreatment; D018570:Risk Assessment; D012307:Risk Factors; D000072657:ST Elevation Myocardial Infarction / Q000000981:diagnostic imaging* / Q000401:mortality / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome
keywords: MVD; culprit vessel intervention; multivessel intervention; primary percutaneous coronary intervention; staged intervention