Staged vs One-Time Multivessel Revascularization in Multivessel CAD

MedicalResearch.com Interview with:
Peter Hu MD Cleveland ClinicPeter T. Hu MD
Department of Cardiology
Cleveland Clinic

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Among patients with blockages in multiple coronary vessels, we studied predictors and outcomes of having a staged versus one-time multivessel percutaneous coronary intervention. By “staged” we mean performing coronary intervention only on one vessel, letting the patient recover, and fixing the other blockages at a later date. We know that multivessel coronary artery disease is very common – present in up to 2/3 of patients who require coronary interventions. Previous studies in patients with STEMI (ST-elevation myocardial infarction) suggested that staged multivessel PCI was associated with lower risk of death compared with one-time multivessel revascularization. Outside of STEMI patients, very little data exist in a broader group of patients who undergo coronary interventions to multiple vessels.

In our study, we found an association between doing a staged PCI and lower long-term mortality benefit compared with fixing multiple blockages at once. What was surprising was there seemed to be a correlation with the degree of benefit from staged PCI based on the symptoms and signs the patient presented with.

The association with improved outcomes was strongest in patients with STEMI, followed by those with NSTEMI, unstable angina, and stable angina, respectively. We also found that the decision to perform staged PCI was driven by patient and procedural characteristics, as well as other unmeasured site variation. 

MedicalResearch.com: What should readers take away from your report?

Response: The biggest message is that the decision to perform one-time multivessel revascularization or staged PCI is really driven by site practices and specific patient characteristics. While the association with improved outcomes is interesting, these findings should be interpreted with caution. Our study is not a randomized trial. There is a randomized trial ongoing (the COMPLETE trial – the principal investigator is Shamir Mehta at PHRI McMaster University) and until the results of that trial are available, our study should not be used to guide practice. 

MedicalResearch.com: What recommendations do you have for future research as a result of this work? 

Response: As mentioned, while the results of our study are interesting, it is important to note that our study was observational in nature. This is not a randomized trial, and we should not be using these data to guide clinical practice. Instead, our study really underscores the importance of getting randomized data to address this practice gap.

I have no conflicts to report. We would like to thank the Department of Veterans Affairs and the CART-CL analytic group at the Denver VA for supporting this important study. Our study demonstrates how the Veterans Affairs has put resources behind understanding how to get the best results for our nation’s veterans with coronary artery disease 

Citation:

JACC: Cardiovascular Interventions

Nov 22, 2018 @ 12:34 am 

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