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Patients with multivessel coronary artery disease who present with stable disease or non-ST-segment elevation myocardial infarction (NSTEMI) face similar mortality risk regardless of whether they receive complete revascularization at the initial hospitalization or as staged procedures, according to a large registry study published online January 15, 2013, ahead of print in Circulation: Cardiovascular Interventions.

Investigators led by Edward L. Hannan, PhD, of the University of Albany, State University of New York (Albany, NY), looked at 15,955 patients with multivessel disease who underwent complete revascularization and were enrolled in the Percutaneous Coronary Intervention Reporting System of New York State between 2007 and 2009. After patients were stratified into those with (n = 5,193) vs. without (n = 5,181) ACS, patients who received complete revascularization during the initial hospitalization were compared with those who underwent staged treatment within 60 days after discharge using Social Security databases.

ACS patients were somewhat more likely to be completely revascularized during the index hospitalization than non-ACS patients (79.4% vs. 69.5%).

After Propensity Matching, No Mortality Difference

To compensate for considerable demographic and clinical differences between staged and unstaged patients, the researchers used propensity matching, creating 1,040 ACS pairs and 1,532 non-ACS pairs. No difference was seen in all-cause mortality rates at 3 years for unstaged vs. staged patients in both the non-ACS group (5.62% vs. 5.97%; P = 0.68) and the ACS group (6.59% vs. 5.92%; P = 0.22). Mortality rates were also similar between the groups at 6 months, 1 year, and 2 years.

The equivalence of the 2 PCI strategies was maintained in ACS and non-ACS patients among subgroups based on age, number of diseased vessels, ejection fraction, glomerular filtration rate, and Medicaid status.

Nonfederal New York hospitals varied widely in their choice of PCI strategy. Among centers with more than 20 NSTEMI multivessel disease patients treated with complete revascularization, 7 (17.5%) had less than 60% of their non-ACS patients receiving one-time procedures, after risk adjustment, while 9 hospitals (22.5%) had more than 90% of patients undergoing complete revascularization during the index admission. For ACS patients, after adjustment, 10 hospitals (23.3%) had less than 70% of their patients undergoing complete revascularization during the index admission, while 17 hospitals (39.5%) followed this practice for at least 90% of these patients.

One-Time Revascularization Preferred

In a telephone interview with TCTMD, Sorin J. Brener, MD, of Weill Cornell Medical College (New York, NY), said that, like his earlier study (Brener SJ, et al. Am Heart J. 2008;155:140-146), this paper shows that there is no penalty to be paid for one-time complete revascularization in NSTEMI patients as long as it is safe, with relatively uncomplicated lesions, and no excessive use of contrast and radiation.

Dr. Brener noted many advantages to the all-at-once approach, including increased comfort and convenience for patients, as well as greater safety from avoiding the risks of repeat catheterization. Such an approach is also more economical in terms of use of the cath lab, technicians, equipment, and anticoagulation medications, he added.

Dr. Brener suggested that the variability in the prevalence of staging from hospital to hospital is likely due to the mix of patients treated. “In hospitals where there are more private patients, doctors prefer to do separate procedures because they are reimbursed much better,” he noted.

Some Important Exceptions

The study results will no doubt put pressure on interventionalists to perform one-time complete revascularization, James C. Blankenship, MD, of Geisinger Medical Center (Danville, PA), told TCTMD in a telephone interview. “But there are important caveats,” he added.

Certain clinical characteristics, such as renal dysfunction, make for a poor candidate for one-time revascularization, Dr. Blankenship observed, and complications occurring during the first part of the procedure may make continuing dangerous.

Complete revascularization can be especially challenging when performed ad hoc, he noted. For example, the operator must consider whether:

• The cath lab schedule can accommodate the extra time needed
• The patient has been fully informed of any increased risk
• The total contrast and radiation exposure will be excessive
• The patient can tolerate the prolonged procedure
• The operator can remain focused to the end

“Looking at this paper and concluding, ‘Everybody should be done as a complete revascularization’ is a wildly simplistic view, and it is certainly not in the patient’s best interest,” Dr. Blankenship commented. “But it’s going to be tempting for insurance companies to say, ‘We’re not going to pay for staged revascularization because now we have proof that there’s no advantage to it.’”

The bottom line is that “for uncomplicated patients with fully informed consent, you’re better off doing PCI in one shot,” he said. “But there are enough exceptions that we shouldn’t have the government or insurers mandate an across-the-board policy in response to this study.”

Dr. Brener said it is important to keep in mind that the study looked only at when to perform complete revascularization, not whether to actually perform such procedures.

Operators need to be flexible, Dr. Blankenship observed. “If you have 1 lesion that is obviously a culprit and another that you’re not sure about and that is high-risk, you may want to [try medical therapy] and wait and see what symptoms [develop],” he proposed.

Overall, Dr. Brener said, focusing too much on the issue of staging can overshadow the underlying finding that regardless of PCI strategy, 3-year mortality rates for unselected patients with multivessel disease are extremely low.

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• Meta-analysis: Multivessel PCI Comparable to Culprit-Only Approach in STEMI