Multivessel PCI Uptake for STEMI ‘Not Exactly High’

Enthusiasm for percutaneous coronary intervention (PCI) in ST-segment elevation MI (STEMI) patients with multivessel disease remained relatively tempered despite the accumulation of positive data, the NCDR CathPCI Registry showed.

Multivessel PCI use in the U.S. declined from 42.7% in the third quarter (Q3) of 2009 to 32.7% in Q2 2013, followed by an increase peaking at 44.0% in Q4 2017, according to researchers led by Eric Secemsky, MD, MSc, of Beth Israel Deaconess Medical Center and Harvard Medical School.

Multivessel PCI performed during the index admission grew more popular over time, rising from 19.3% of STEMI cases in Q3 2009 to 31.8% in Q1 2018.

Post-discharge staged multivessel PCI, on the other hand, fell from favor (from 23.4% in Q3 2009 to 9.9% in Q4 2014), Secemsky’s group showed in a paper published online in JAMA Cardiology.

These changes in multivessel PCI use roughly tracked the emerging evidence — first the publication of negative observational studies and meta-analyses, then the publication of PRAMI and other positive trials starting in 2013.

“By the time the 2015 American College of Cardiology Foundation/American Heart Association/Society for Cardiovascular Angiography & Intervention STEMI PCI guideline was published with an updated recommendation of class IIb, national use had already exceeded 40% and remained close to this level for the remainder of the study period,” according to the investigators.

Yet the clinicians’ response to changes in evidence has been “modest at best,” as described by John Bittl, MD, of AdventHealth Ocala, Florida, in an accompanying editorial.

“The absolute difference of 11 percentage points between the nadir and the peak means that the use of multivessel PCI changed in only 1 of 9 patients. This is not exactly high uptake, which probably reflects the belief throughout all periods that culprit-only PCI is the default strategy, with preemptive PCI on nonculprit vessels being reserved for special circumstances,” he said.

“The theoretical benefit of multivessel PCI may include stabilization of all potentially unstable plaques, but as a counterargument, multivessel PCI entails greater contrast use and a higher risk of acute kidney injury. Another argument against routine multivessel PCI at the same time as culprit-vessel PCI is avoidance of overuse, based on the realization that the severity of a nonculprit stenosis is often overestimated during infarct angiography,” he noted.

Multivessel PCI may continue to grow, Secemsky’s team noted, given that the COMPLETE trial demonstrating superiority of complete revascularization over culprit-only PCI for STEMI was published in 2019 (after Secemsky’s study period) and has not been incorporated into professional guidance.

“Timely guideline changes are critical to help standardize operator practices and assure that the highest quality of care is being delivered uniformly,” Secemsky and colleagues said.

The study counted all admissions in the NCDR CathPCI Registry from July 1, 2009, to March 30, 2018, and identified 359,879 cases with STEMI and multivessel disease.

During this period, multivessel PCI was performed in 38.5% of cases, split among procedures performed during the index procedure (30.8%), staged procedures during index hospitalization (31.6%), and staged procedures within 45 days of discharge (37.6%).

Baseline and procedural characteristics were similar between patients who did and did not receive multivessel PCI.

Multivessel PCI use markedly varied across centers, the researchers noted.

The authors cautioned that they had examined trends in multivessel PCI, not the complete revascularization assessed in the COMPLETE trial. However, complete revascularization of all diseased arteries had been performed in 76.2% of those who underwent multivessel PCI in the registry.

Another major limitation was that data were self-reported by centers and subject to potential misclassification.

“Clinicians have been forced to wade through a morass of conflicting reports and a slew of contradictory guidelines that have gone around in circles and still not reached a consensus about the timing of multivessel PCI or provided a consistent recommendation for patients with or without cardiogenic shock,” Bittl complained.

There will certainly be more studies on multivessel PCI, the editorialist predicted.

“The jumble of evidence for and against multivessel PCI is reminiscent of Jarndyce and Jarndyce, a legal case that became a plot device in the masterful novel Bleak House, which Charles Dickens wrote to expose the maneuverings of the English equity court notorious for blocking settlements to deserving,” he wrote.

“As with old English equity law, the clinical investigation of multivessel PCI has thrived on contradictory findings that produce little change in practice and, despite all good intentions, has only benefited the experts who need to keep publishing.”