Multivessel CAD: staged PCI offers lower mortality vs one-time MVR

  • Hu PT & al.
  • JACC Cardiovasc Interv
  • 26 Nov 2018

  • curated by Jenny Blair, MD
  • Clinical Essentials
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Takeaway

  • In patients with multivessel coronary artery disease (CAD), staged percutaneous coronary intervention (PCI) is associated with lower mortality than one-time (OT) multivessel revascularization (MVR).
  • Staged-PCI rates vary by site for unclear reasons.
  • Randomized trial is needed. 

Why this matters

  • The best timing for multivessel revascularization remains unclear.

Key results

  • 36.1% underwent staged PCI; 63.9% underwent OTMVR.
  • Staged PCI likelier if patient had chronic kidney disease, 3- vs 2-vessel disease, ST-segment elevation myocardial infarction (STEMI).
  • It was also, as expected, likelier at high- vs low-likelihood sites (OR, 0.20-5.08).
  • All-cause mortality with staged PCI vs OTMVR (median follow-up, 43.7 months) (HRs; 95% CIs):
    • All comers, with propensity-score adjustment: 0.78 (0.72-0.84; P<.01>
    • Acute coronary syndrome, adjusted: 0.73 (0.66-0.81; P<.01>
    • STEMI: 0.31 (0.21-0.47; P<.01>
    • Non-STEMI: 0.74 (0.64-0.87; P<.01>
    • Unstable angina: 0.75 (0.64-0.89; P<.01>
    • Stable angina: 0.88 (0.77-1.00; P=.048).
  • Similar between-group transfusion rates.

Study design

  • Analysis of Veterans Affairs Clinical Assessment, Reporting, and Tracking Program.
  • Participants at 61 sites had undergone PCI of >2 vessels (n=7599).
  • Authors used propensity matching to compare mortality with staged PCI vs OTMVR.
  • Funding: Authors disclose industry, nonprofit, government funding.

Limitations

  • Observational data; unmeasured confounders.

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