Should Bystander Coronary Arteries Be Treated At Same Time As Primary PCI?

MedicalResearch.com Interview with:
Dr. Bilal Iqbal MD
Royal Brompton and Harefield NHS Foundation Trust
Harefield Hospital
Middlesex United Kingdom.

Medical Research: What is the background for this study? What are the main findings?

Dr. Iqbal: The optimal strategy for revascularization of bystander coronary disease at the time of PPCI is unknown. Certainly, this has been the focus of recent debate and randomized controlled trials. We evaluated a strategy of culprit vessel versus multivessel intervention at the time PPCI in the real world setting. We conducted an observational analysis of 3984 consecutive patients with STEMI undergoing Primary percutaneous coronary intervention (PPCI) who had multivessel disease. We excluded patients with cardiogenic shock and patients with bystander LMS disease, which may potentially dictate staged surgical intervention. When analysing all-cause mortality at 1 year, we found that a strategy of culprit vessel intervention only at the time of PPCI was associated with increased survival at 1 year.

Medical Research: What should clinicians and patients take away from your report?

Dr. Iqbal: We have to acknowledge the limitations of observational analyses particularly in relation to confounders. Although we used various statistical methodologies to address measured confounders, unmeasured confounders do exist which may have affected the results. Although the PRAMI and CVLPRIT trials have shown a strategy of complete revascularization may be superior, the composite end-points in these studies included outcomes which may themselves be dictated by treatment strategy, e.g. refractory angina and ischaemia-driven revascularisation. When specifically looking at mortality, no difference in mortality was found between the two strategies in either study. Whilst the PRAMI and CVLPRIT trials have certainly added to the current evidence base, further studies are warranted to further refine our treatment strategies for STEMI patients with multivessel disease. Given the observational nature of our study, the results of our study should be considered as hypothesis generating.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Iqbal: Further trials are required to define the optimum revascularization for patients and with STEMI and multivessel disease. An important question stemming from recent trials is whether complete revascularisation at the time of PPCI or whether prior to hospital discharge is associated with better outcomes.

Citation:

Culprit Vessel Versus Multivessel Intervention at the Time of Primary Percutaneous Coronary Intervention in Patients With ST-Segment–Elevation Myocardial Infarction and Multivessel Disease: Real-World Analysis of 3984 Patients in London

M. Bilal Iqbal, Charles Ilsley, Tito Kabir, Robert Smith, Rebecca Lane, Mark Mason, Piers Clifford, Tom Crake, Sam Firoozi, Sundeep Kalra, Charles Knight, Pitt Lim, Iqbal S. Malik, Anthony Mathur, Pascal Meier, Roby D. Rakhit, Simon Redwood, Mark Whitbread, Dan Bromage, Krishna Rathod, Philip MacCarthy, and Miles Dalby

Circ Cardiovasc Qual Outcomes. 2014;CIRCOUTCOMES.114.001194published online before print November 4 2014, doi:10.1161/CIRCOUTCOMES.114.001194

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