Original title: Staged Versus One-time Complete Revascularization With Percutaneous Coronary Intervention for Multivessel Coronary Artery Disease Patients Without ST-Elevation Myocardial Infarction. Reference: Edward L. Hannan et al. Circ Cardiovasc Interv 2013;6;12-20.
There is evidence that in patients with multi-vessel disease affected by an acute coronary syndrome (ACS) with ST segment elevation, only the cause lesion should be treated and other lesions should be deferred unless there is hemodynamic instability.
However, in patients with ACS but without ST elevation the stable patients’ strategy is not so clear and there is great variability between centers. The aim of this observational study was to examine the mortality rate of multi-vessel disease patients after 3 years, stable or with ACS but without ST elevation, which underwent complete revascularization (CR) in the same procedure versus CR in stages, (within 60 days of the index procedure).
We included a total of 5,193 patients with ACS but without ST elevation, (79.4% in the same CR procedure versus 20.6% who received CR in stages) and 5,181 chronic stable patients, (69.5% in the same CR procedure versus 30.5% who received CR in stages). A Propensity score was used to match the differences in baseline characteristics to analyze 2,080 patients with ACS but without ST elevation and 3,064 chronic stable patients. In patients with ACS but without ST elevation we observed a mortality rate after 3 years in the RC branch in the same procedure of 6.59% versus 5.92% in the RC branch in stages, (p = 0.22). In chronic stable patients we observed a mortality rate after 3 years in the RC branch in the same procedure of 5.62% versus 5.97% of the RC branch in stages, (p = 0.68). Mortality for both groups was similar at 6 months, 1 year and 2 years.
Conclusion:
The 3 year mortality rate was similar in patients who underwent complete revascularization in the same procedure versus complete revascularization in stages both for those suffering an acute coronary syndrome without ST segment elevation and those with chronic stable.
Editorial comment:
The study excluded those patients that might have had clinical or anatomical reasons for proceeding in stages like those with total occlusions, renal failure or receiving a high volume of contrast during the first half of the procedure. It is a limitation of the study only to analyze mortality without information on other points like renal injury by contrast or periprocedural enzyme elevation. Beyond this, complete revascularization in the same procedure or in stages within 60 days seems equivalent in terms of long-term mortality allowing us to discuss both the patient and the primary care strategy to follow more calmly. Another useful point is the saving to the health system in hospital costs when performing a single procedure. However, this should be analyzed according to the policies of individual countries.
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