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CLINICAL RESEARCH: ACUTE CORONARY SYNDROME

In Unstable Angina or Non–ST-Segment Acute Coronary Syndrome, Should Patients With Multivessel Coronary Artery Disease Undergo Multivessel or Culprit-Only Stenting?

Mehdi H. Shishehbor, DO, MPH^_*,1, Michael S. Lauer, MD, FACC^_*, Inder M. Singh, MD, MS, Derek P. Chew, MBBS, MPH, Juhana Karha, MD^_*, Sorin J. Brener, MD, FACC^_*, David J. Moliterno, MD, FACC^,2, Stephen G. Ellis, MD, FACC^_*, Eric J. Topol, MD, FACC^|| and Deepak L. Bhatt, MD, FACC^_*,3,_*

^_* Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
Department of Cardiology, Flinders Medical Center, South Australia, Australia
Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
^|| Department of Genetics, Case Western Reserve University, Cleveland, Ohio

Manuscript received August 15, 2006; revised manuscript received October 12, 2006, accepted October 17, 2006.

^_* Reprint requests and correspondence to: Dr. Deepak L. Bhatt, Department of Cardiovascular Medicine, Desk F-25, 9500 Euclid Avenue, Cleveland, Ohio 44195. (Email: bhattd{at}ccf.org).

OBJECTIVES: We examined the safety and efficacy of nonculprit multivessel compared with culprit-only stenting in patients with multivessel disease presenting with unstable angina or non–ST-segment elevation myocardial infarction (non–ST-segment elevation acute coronary syndromes [NSTE-ACS]).

BACKGROUND: In patients presenting with NSTE-ACS, multivessel coronary artery disease (CAD) is associated with adverse outcome.

METHODS: Patients with multivessel CAD and NSTE-ACS that underwent percutaneous coronary intervention were included. The culprit lesion was defined by reviewing each patient’s angiographic report, electrocardiogram, echocardiogram and, if available, nuclear stress test. All patients had at least 2 vessels with 50% stenosis, and the angiographic severity of CAD was assessed using the Duke Prognostic Angiographic Score. Patients with coronary bypass grafts, chronic total occlusions, and those with uncertain culprit lesions were excluded. Our end point was the composite of death, myocardial infarction, or any target vessel revascularization.

RESULTS: From January 1995 to June 2005, 1,240 patients with ACS and multivessel CAD underwent percutaneous coronary intervention with bare-metal stenting and met our study criteria. Of these, 479 underwent multivessel and 761 underwent culprit-only stenting. There were 442 events during a median follow-up of 2.3 years. Multivessel intervention was associated with lower death, myocardial infarction, or revascularization after both adjusting for baseline and angiographic characteristics (hazard ratio 0.80; 95% confidence interval 0.64 to 0.99; p = 0.04) and propensity matched analysis (hazard ratio 0.67; 95% confidence interval 0.51 to 0.88; p = 0.004).

CONCLUSIONS: In patients with multivessel CAD presenting with NSTE-ACS, multivessel intervention was significantly associated with a lower revascularization rate, which translated to a lower incidence of the composite end point compared with culprit-only stenting.

Abbreviations and Acronyms   CAD = coronary artery disease   MI = myocardial infarction   NSTE-ACS = non–ST-segment elevation acute coronary syndromes (unstable angina and non–ST-segment myocardial infarction)   NSTEMI = non–ST-segment elevation myocardial infarction   PCI = percutaneous coronary intervention

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