Institutional adoption patterns are mixed, but multivessel (MV) percutaneous coronary intervention (PCI) is gaining ground over the guideline-recommended and leading treatment of ST-elevation myocardial infarction (STEMI), culprit-only PCI, according to a nationwide analysis. As Dr. Eric A. Secemsky told Reuters Health by email, "We found substantial temporal variation in use of multivessel PCI among patients with multivessel coronary disease and STEMI, which coincided with emerging evidence. At the end of our study, MV PCI was on the rise, but still pursued in the minority of STEMI patients." "In the context of the positive COMPLETE trial," he added, "the largest trial to date that demonstrated a clinical benefit with complete revascularization of all diseased vessels, we anticipate a large change in clinical care as these results are adopted into routine practice." To determine the impact of these findings, Dr. Secemsky of Harvard Medical School, in Boston, and colleagues examined data from close to 1,600 institutions in the National Cardiovascular Data Registry. There were nearly 360,000 admissions of patients with STEMI and MV disease between 2009 and 2018, they report in JAMA Cardiology. MV PCI was performed in 38.5% of admissions within 45 days and use across institutions ranged from 30.0% to 46.5%, with a median of 37.9%. Complete revascularization of all diseased arteries took place in 76.2% of these patients and although there was a dip in MV PCI use between 2009 and 2013, this was followed by an increase to 44.0% in 2017. Current American College of Cardiology Foundation/American Heart Association STEMI guidelines recommend against routine use of MV PCI and, say the researchers, "lagged behind clinician behavior. While it is reassuring that clinicians respond to new data, this rapid change in practice may lead to harm if there is no consensus that these data are sufficient to promote widespread adoption." Dr. John A. Bittl of AdventHealth, in Ocala, Florida, who wrote an accompanying editorial, told Reuters Health by email, "When it comes to the decision about multivessel PCI during STEMI, the results of randomized trials have put clinicians and guideline committees into an awkward position." Dr. Bittl added, "My personal opinion is that culprit-vessel-only PCI is the default strategy for all patients with STEMI, with multivessel PCI being reserved for situations involving two culprit lesions or for prognostically important locations such as the left main coronary artery." The current analysis "suggests that this approach is the standard of care." —David Douglas Source
