Clinical Question

Does performing preventive percutaneous coronary intervention (PCI) in noninfarct arteries during emergency myocardial infarction (MI) PCI reduce adverse cardiovascular events in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease?

Bottom Line

Preventive PCI in noninfarct arteries with significant stenosis during primary PCI for STEMI significantly reduces the risk of future adverse cardiovascular events compared to treating the infarct artery alone.

Major Points

Guidelines

Current guidelines recommend PCI of the infarct artery only in STEMI patients with multivessel disease, owing to previous lack of evidence regarding the value of preventive PCI.

Design

Population

The trial enrolled 465 patients with acute STEMI and multivessel coronary disease detected at the time of emergency PCI for the infarct artery.

Inclusion Criteria:
- Acute STEMI, including three patients with left bundle-branch block
- Successful PCI treatment of the infarct artery
- Stenosis of ≥50% in other coronary arteries treatable by PCI

Exclusion Criteria:
- Cardiogenic shock
- Previous coronary-artery bypass grafting
- Ineligibility due to other specified concerns

Interventions

Patients were randomized to receive either no further PCI procedures after the infarct-artery PCI (n=231) or to undergo immediate preventive PCI in noninfarct arteries with >50% stenoses (n=234).

Outcomes

The primary outcome was a composite of death from cardiac causes, nonfatal myocardial infarction, or refractory angina.

Major Points

Primary outcomes occurred in 21 patients in the preventive-PCI group and 53 in the infarct-artery-only PCI group, revealing a significant hazard ratio of 0.35 in favor of preventive PCI. Hazard ratios for death from cardiac causes, nonfatal MI, and refractory angina were also in favor of preventive PCI.

Criticisms

The study did not address whether the benefits of preventive PCI extend to patients with non-STEMI or whether immediate or delayed (staged) preventive PCI is superior.

Funding

Supported by Barts and the London Charity.

Further Reading

The article was published on September 1, 2013, at NEJM.org.