SNOWMASS, COLO. – Recent data seem to refute the 2013 American Heart Association/American College of Cardiology class III recommendation to avoid multivessel percutaneous coronary intervention at the time of primary PCI for ST-elevation MI, Dr. David R. Holmes Jr. observed at the Annual Cardiovascular Conference at Snowmass.
“The current AHA/ACC guidelines for STEMI should be and are being reevaluated regarding clarifications for the indications and timing of non–infarct artery revascularization,” according to Dr. Holmes, a cardiologist at the Mayo Clinic in Rochester, Minn., and an ACC past president.
Dr. David R. Holmes Jr.
Indeed, the ACC has already withdrawn from its ‘Choosing Wisely’ campaign its former recommendation discouraging multivessel revascularization at the time of primary PCI for STEMI. The college cited “new science showing that complete revascularization of all significant blocked arteries leads to better outcomes in some heart attack patients.”
Dr. Holmes was coauthor of a meta-analysis of 4 prospective and 14 retrospective studies involving more than 40,000 patients that concluded multivessel PCI for STEMI should be discouraged, and that significant nonculprit lesions should only be treated during staged procedures (J. Am. Coll. Cardiol. 2011;58:692-703). This meta-analysis was influential in the creation of the class III ‘don’t do it’ recommendation in the AHA/ACC guidelines. But Dr. Holmes said that in hindsight, the data included in the meta-analysis were something of a mishmash and “wound up being very hard to interpret.”
Greater clarity has been brought by two more recent randomized trials: PRAMI and CvLPRIT. Both were relatively small by cardiology standards, but they ended up showing similarly striking advantages in favor of using the STEMI hospitalization to perform preventive PCI of both the infarct-related artery and non–infarct arteries with major stenoses.
PRAMI included 465 acute STEMI patients who underwent infarct artery PCI and were then randomized to preventive PCI or infarct artery–only PCI. At a mean follow-up of 23 months, the preventive multivessel PCI group had a 65% reduction in the relative risk of the primary outcome, a composite of cardiac death, nonfatal MI, or refractory angina (N. Engl. J. Med. 2013;369:1115-23).
The yet-to-be-published CvLPRIT study was presented at the 2014 European Society of Cardiology meeting in Barcelona. The multicenter study included 296 STEMI patients with angiographically established significant multivessel disease who were randomized to primary PCI of the culprit vessel only or to complete revascularization. The primary outcome, the 12-month composite of all-cause mortality, recurrent MI, heart failure, or ischemia-driven revascularization, occurred in 10% of the complete revascularization group, compared with 21.2% of patients assigned to culprit artery–only PCI.
Also at the ESC conference, CvLPRIT investigator Dr. Anthony Gershlick of the University of Leicester (England) presented a meta-analysis combining the weighted results of PRAMI, CvLPRIT, and two earlier randomized trials: HELP AMI (Int. J. Cardiovasc. Intervent. 2004;6:128-33) and an Italian trial (Heart 2010;96:662-7). The results strongly favored multivessel PCI, with a 45% reduction in mortality and a 61% decrease in recurrent MI, compared with culprit vessel–only PCI at the time of admission for STEMI.
“Maybe there aren’t any innocent bystanders,” commented Dr. Holmes. “Maybe if you have somebody who has multivessel disease and you see something you think might be an innocent bystander but is a significant lesion, maybe it’s not so innocent. Maybe by treating them all at the time of the initial intervention the patient is going to do better.”
He reported having no financial conflicts of interest regarding his presentation.