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. Author manuscript; available in PMC: 2016 Nov 10.
Published in final edited form as: J Am Coll Cardiol. 2015 Nov 10;66(19):2104–2113. doi: 10.1016/j.jacc.2015.08.873

Impact of Multivessel Revascularization on Health Status Outcomes in Patients with ST-Elevation Myocardial Infarction and Multivessel Coronary Disease

Jae-Sik Jang *,†,‡, John A Spertus *,†, Suzanne V Arnold *,†, Ali Shafiq *,†, Anna Grodzinsky *,†, Timothy J Fendler *,†, Adam C Salisbury *,†, Fengming Tang *, Edward J McNulty §, J Aaron Grantham *,†, David J Cohen *,†, Amit P Amin ||,
PMCID: PMC4638151  NIHMSID: NIHMS721409  PMID: 26541921

Abstract

BACKGROUND

Up to 65% of patients with ST-elevation myocardial infarction (STEMI) have multivessel coronary disease (MVCAD). TLong-term health status of STEMI patients following multivessel revascularization is unknown.

OBJECTIVE

We investigated the relationship between multivessel revascularization and health status outcomes (symptoms and quality of life [QoL]) in STEMI patients with MVCAD.

METHODS

Using a U.S. myocardial infarction registry and the Seattle Angina Questionnaire (SAQ), we determined the health status of patients with STEMI and MVCAD at the time of STEMI and 1 year later. We assessed the association of multivessel revascularization during index hospitalization with 1-year health status using multivariable linear regression analysis, and also examined demographic, clinical, and angiographic factors associated with multivessel revascularization.

RESULTS

Among 664 STEMI patients with MVCAD, 251 (38%) underwent multivessel revascularization. Most revascularizations were staged during the index hospitalization (64.1%), and 8.0% were staged after discharge, with 27.9% performed during primary PCI. Multivessel revascularization was associated with age and more diseased vessels. At 1 year, multivessel revascularization was independently associated with improved symptoms (4.5 points higher SAQ angina frequency score; 95% CI: 1.0 to 7.9) and QoL (6.6 points higher SAQ QoL score; 95% CI: 2.7 to 10.6). One year mortality was not different between those who did and did not undergo multivessel revascularization (3.6% vs. 3.4%; log-rank test p = 0.88).

CONCLUSIONS

Multivessel revascularization improved angina and QoL in STEMI patients with MVCAD. Patient-centered outcomes should be considered in future trials of multivessel revascularization.

Keywords: Myocardial infarction, Percutaneous coronary intervention, Quality of health care

Among ST-elevation myocardial infarction (STEMI) patients, 40% to 65% have 1 or more significant coronary stenoses in addition to their culprit vessels (1). When and how to treat these non-culprit vessels is controversial (2). Options include revascularization at the time of primary percutaneous coronary intervention (PCI), later during the acute myocardial infarction (AMI) hospitalization, or medical therapy with or without subsequent elective revascularization after discharge. Current guidelines recommend that only the culprit vessel be treated during index PCI in the absence of hemodynamic instability after opening the culprit artery (3,4), with staged procedures being considered in case of symptoms or ischemia within days to weeks after primary PCI (5).

Recently several observational studies have been published with conflicting results about the benefits of non-culprit PCI (6–8). These observational studies have been supplemented with randomized trials, including Preventive Angioplasty in Acute Myocardial Infarction (PRAMI) (9) and Complete versus Lesion only Primary-PCI Trial (CvLPRIT) (10), that have reported better composite outcomes in STEMI patients treated with complete revascularization at the time of primary PCI or during the index hospitalization. Importantly, these studies did not examine patient-reported outcomes, and there have been no data reported on the long-term health status outcomes of culprit-only or multivessel revascularization. This is particularly important as reduced angina and improved quality of life (QoL) could be important potential benefits of treating non-culprit flow-limiting lesions, similar to the results of studies in population of patients with stable coronary artery disease (11,12). To define the potential patient-centered benefits of complete revascularization, we sought to describe the patterns of treating non-infarct vessels, patient characteristics associated with multivessel revascularization, variation in practice across hospitals, and the independent association of multivessel revascularization with 1-year health-related QoL and mortality.

METHODS

STUDY PROTOCOL AND POPULATION

The Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients’ Health Status (TRIUMPH) study is a prospective, multicenter cohort study of 4,340 AMI patients enrolled at 24 U.S. centers between April 2005 and December 2008. Patients were eligible for inclusion if they were ≥ 18 years of age and had an AMI, and elevated biomarkers with either electrocardiographic changes or symptoms consistent with the diagnosis (13). TRIUMPH was approved by the institutional research board at each participating site and written informed consent was obtained from all participants.

From the overall TRIUMPH cohort, we first identified patients with STEMI and multivessel coronary disease (MVCAD), which was defined as having at least 2 of 3 epicardial vessels with a stenosis ≥ 70% or left main stenosis ≥ 50%. Given the goal of examining practice patterns and long-term outcomes in STEMI patients with MVCAD, we excluded those with non-ST-elevation myocardial infarction (NSTEMI), prior coronary artery bypass grafting (CABG), and those who died during hospitalization.

DEFINITION OF MULTIVESSEL REVASCULARIZATION

Multivessel revascularization was defined as revascularization of all major coronary stenoses during the index hospitalization or within 6 weeks of discharge with either PCI or CABG, such that there was no residual stenosis ≥ 70% in any major epicardial coronary artery. This definition included simultaneous non-culprit PCI during the index primary PCI, staged revascularizations during the index admission and elective procedures performed within 6 weeks of discharge. For patients undergoing CABG during the index hospitalization or within 6 weeks of discharge, we assumed that complete revascularization had been performed. Conversely, we defined culprit-only revascularization as PCI to the culprit vessel only during the index hospitalization or multivessel PCI with residual untreated or unsuccessfully treated non-infarct artery stenoses ≥ 70% after the index primary PCI.

OUTCOMES

Disease-specific health status was prospectively assessed using the Seattle Angina Questionnaire (SAQ) at the time of patients’ index hospitalizations and at 1-year follow-up. The SAQ is a 19-item patient-reported health status instrument with a recall period of 4 weeks that quantifies 5 clinically-relevant domains of coronary disease, including angina frequency (SAQ AF) and quality of life (SAQ QoL). Scores in these domains range from 0–100, with higher scores indicating fewer symptoms and better QoL (14). The SAQ has been demonstrated to be valid, reliable, and sensitive to clinical changes (14–17) and is also associated with subsequent rehospitalization and healthcare costs (18–20). As a secondary outcome of interest, we assessed all-cause mortality for a period of 1 year following the index admission using a combination of phone follow-up and the Social Security death master index. We also examined the rates of severe angina (defined as having more than 3 episodes of angina per week as defined by a SAQ AF score of ≤ 40), myocardial infarction, and repeat revascularization procedures (PCI or CABG) during the year after patients’ initial AMI.

STATISTICAL ANALYSIS

Baseline clinical and demographic characteristics were compared between those with multivessel versus culprit-only revascularization using t-test or Mann-Whitney U tests for continuous variables and chi-square or Fisher’s exact test for categorical variables, as appropriate. To identify factors associated with multivessel revascularization, we used a multivariable, hierarchical (adjusting for site as a random effect) modified Poisson regression model with robust variance estimation (21). Factors included in the model were selected a priori, based on literature review and clinical judgment, and included age, sex, race, history of atrial fibrillation, diabetes mellitus and congestive heart failure, left ventricular systolic function, number of diseased vessels, non-left anterior descending (LAD) artery as the culprit artery, development of in-hospital heart failure after the primary PCI, baseline creatinine, baseline hemoglobin, short form-12 physical component scale score at baseline, presence of angina prior to admission, financial status and avoidance of health care services due to cost. Variation in the practice of multivessel revascularization across the study sites was assessed using the median rate ratio (MRR) (22,23).

The association of multivessel revascularization with 1-year health status outcomes was evaluated using hierarchical (adjusting for site as a random effect) multivariable linear regression models for each health status outcome (SAQ AF and SAQ QoL). Covariates for adjustment were selected a priori, based on literature review and clinical judgment, and included baseline health status scores, age, sex, race, history of smoking, number of diseased vessels, non-LAD as the culprit artery, in-hospital heart failure after the primary PCI, baseline creatinine, baseline hemoglobin, and self-reported avoidance of health care services due to cost. Since these models included baseline health status, the regression coefficient for the ‘multivessel’ versus culprit-only artery revascularization variable represented the difference between these 2 groups in the improvement of the health status scores from baseline to 1 year, adjusted for all covariates.

The associations of multivessel revascularization with 1-year mortality, myocardial infarction, and repeat revascularization were assessed using Kaplan-Meier survival analysis and the log-rank test. Finally, we performed a sensitivity analysis excluding patients undergoing CABG to determine whether our results were comparable in the PCI-only patients. All statistical analyses were conducted using SAS v9.3 (SAS Institute Inc, Cary, NC).

MISSING DATA

Two hundred twenty-four (33.7%) of the 664 patients did not have a follow-up SAQ score at 1 year. Outcomes data were missing equally in the 2 groups. Baseline characteristics were compared between those with versus without missing data and we sought to minimize the effect of selection bias (due to loss-to-follow-up) by constructing a non-parsimonious, multivariable logistic regression model to determine the probability of having missing data. We then weighted each of the observed patients by the inverse probability of the likelihood to having missing data (24) so that we preferentially weighted the experience of those most like the patients who were missing follow-up assessments.

RESULTS

PATIENT POPULATION

Of the 4,340 patients enrolled in TRIUMPH, 537 patients with a history of prior CABG were excluded. We also excluded 2,218 patients with single vessel coronary disease or who did not undergo diagnostic angiography. We further excluded 406 NSTEMI patients and 4 patients who died prior to discharge, making our final analytic cohort 664 patients with STEMI and multivessel coronary disease (Figure 1). Among these, 413 (62%) underwent culprit-only PCI and 251 (38%) underwent multivessel revascularization. Of those undergoing complete revascularization, most were staged during index hospitalization (n = 161, 64.1%), 20 (8.0%) were performed shortly after discharge, and 70 (27.9%) were treated during their primary PCI. The mode of multivessel revascularization was percutaneous in 88% of patients. The baseline characteristics of those who underwent multivessel versus culprit-only revascularization are displayed in Table 1. Patients undergoing multivessel revascularization were younger, had less history of prior PCI, had higher peak troponin and hemoglobin level, received more drug-eluting stents, had a greater number of diseased vessels, and were more likely to have proximal LAD artery involvement of the non-culprit artery.

Figure 1. Study inclusion and exclusion criteria.

Figure 1

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CAD = coronary artery disease; CABG = coronary artery bypass grafting; NSTEMI = non-ST-elevation myocardial infarction; PCI = percutaneous coronary intervention; STEMI = ST-elevation myocardial infarction; TRIUMPH = Translational Research Investigating Underlying disparities in acute Myocardial infarction Patients’ Health Status.

Table 1.

Baseline demographic and clinical characteristics by categories of multivessel vs. culprit-only revascularization

Multivessel n = 251 Culprit-only n = 413 P-Value
Socio-demographic Variables
 Age 56.4 ± 10.0 58.7 ± 12.1 0.012
 Caucasian 197 (79.4%) 299 (72.7%) 0.053
 Female gender 62 (24.7%) 108 (26.2%) 0.678
 Insurance: None/Self-Pay 58 (23.7%) 92 (22.9%) 0.830
Medical History and Clinical Variables
 Diabetes 59 (23.5%) 106 (25.7%) 0.532
 Hypertension 144 (57.4%) 242 (58.6%) 0.756
 Dyslipidemia 115 (45.8%) 190 (46.0%) 0.962
 Prior PCI 29 (11.6%) 78 (18.9%) 0.012
 Chronic heart failure 5 (2.0%) 8 (1.9%) 1.000
 Peripheral vascular disease 5 (2.0%) 16 (3.9%) 0.179
 Smoking 156 (62.2%) 252 (61.0%) 0.770
 In-hospital heart failure 15 (6.0%) 15 (3.6%) 0.158
 LV dysfunction (EF < 40%) 43 (18.4%) 79 (21.0%) 0.438
 Peak troponin I/T (ng/dL): (Median) 23.8 13.7 < 0.001
 Hemoglobin (g/dL): Initial (Median) 15.0 14.7 0.035
 Systolic BP (mmHg): Initial (Median) 142.0 140.0 0.443
Angiographic and Procedural Characteristics
 Number of diseased vessels 2.5 ± 0.7 2.4 ± 0.6 < 0.001
 Number of vessels treated 1.9 ± 0.6 1.0 ± 0.0 < 0.001
 Distribution of culprit vessels < 0.001
  Left main coronary artery 1 (0.4%) 3 (0.7%)
  Proximal left anterior descending artery 45 (17.9%) 31 (7.5%)
  Mid to distal left anterior descending artery 42 (16.7%) 116 (28.1%)
  Left circumflex artery 23 (9.2%) 50 (12.1%)
  Right coronary artery 109 (43.4%) 181 (43.8)
  Other 1 (0.4%) 3 (0.7%)
  Unknown 30 (12.0%) 29 (7.0%)
 Left anterior descending artery culprit 87 (34.7%) 147 (35.6%) 0.807
 Distribution of non-culprit vessels
  Left main coronary artery 10 (4.0%) 18 (4.4%) 0.815
  Proximal left anterior descending artery 25 (10.0%) 12 (2.9%) < 0.001
  Mid to distal left anterior descending artery 119 (47.4%) 169 (40.9%) 0.101
  Left circumflex artery 112 (44.6%) 206 (49.9%) 0.188
  Right coronary artery 74 (29.5%) 134 (32.4%) 0.424
  Other 26 (10.4%) 28 (6.8%) 0.101
 Number of bare-metal stents 0.8 ± 1.2 0.7 ± 0.9 0.556
 Number of drug-eluting stents 1.6 ± 1.6 0.7 ± 0.9 < 0.001
In-Hospital Revascularization < 0.001
 PCI 223 (88.8%) 413 (100%)
 CABG 28 (11.2%) 0
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Values are mean ± SD, n (%) or median. BP = blood pressure; CABG = coronary artery bypass grafting; EF = ejection fraction; LV = left ventricular; PCI = percutaneous coronary intervention.

FACTORS ASSOCIATED WITH MULTIVESSEL RVASCULARIZATION

The factors independently associated with multivessel revascularization were the number of diseased vessels (relative risk: 1.31 per additional vessel; 95% CI: 1.17 to 1.46) and age (Figure 2). Age displayed a non-linear, inverse J-shaped association with multivessel revascularization. While older patients were less likely to receive multivessel revascularization, as compared with patients around age 50, the youngest patients also showed a trend towards less multivessel revascularization, which was not statistically significant (Online Figure 1).

Figure 2. Independent correlates of multivessel revascularization.

Figure 2

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X-axis shows the rate ratio for undergoing multivessel revascularization. Age and number of diseased vessels were independently associated with multivessel revascularization. CHF = chronic heart failure; CR = complete revascularization; LAD = left anterior descending; LV = left ventricular; SF-12 PCS = short form-12 physical component scale score.

The average rate of multivessel revascularization across the population was 38%; however, we observed marked variation across study sites, ranging from 0% to > 70% (Figure 3). The MRR, a statistical measure of variation was 1.30, suggesting an average 30% greater likelihood of undergoing multivessel revascularization for patients with identical characteristics who present at one randomly selected TRIUMPH site as compared with another.

Figure 3. Hospital variation in the rate of multivessel revascularization.

Figure 3

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X-axis shows individual hospital sites arranged in increasing order of their rate of ‘multivessel revascularization.’ Median rate ratio, a statistical measure of variation was 1.30, suggesting an average 30% higher likelihood of undergoing multivessel revascularization for patients with identical characteristics who present to two randomly selected TRIUMPH sites.

MULTIVESSEL VERSUS CULPRIT-ONLY REVASCULARIZATION AND HEALTH STATUS OUTCOMES

Among the 664 eligible patients, 224 (33.7%) did not have a follow-up SAQ score at 1 year. These data were missing equally in the 2 groups and were addressed with inverse probability weighting to preferentially weight the experience of patients most like those missing follow-up data. There were improvements in unadjusted health status from baseline to 1 year in both groups (Table 2), although these improvements were greater in the multivessel revascularization group. On average, the unadjusted SAQ AF score in the multivessel group was 4.09 points higher than the culprit only group (95% CI; 0.56 to 7.63; Figure 4A). The proportion of patients complaining of severe angina (i.e. more than 3 angina episodes per week) at 1 year was not significantly different between the two groups (4.4% vs. 6.3%; p = 0.34; Table 2). The unadjusted SAQ QoL score was also significantly greater in the multivessel group by 5.18 points (95% CI; 1.17 to 9.19). After multivariable regression with inverse probability weighting to adjust for baseline patient characteristics, there was a significant difference in the degree of improvement from baseline to 1 year between the groups of patients who underwent complete, as compared with culprit only, revascularization. The SAQ AF score was 4.45 points (95% CI: 0.99 to 7.91) higher and the SAQ QoL score was 6.63 points (95% CI: 2.67 to 10.59; Figure 4A) higher with multivessel vs. culprit-only revascularization. The interaction of the timing of complete revascularization (at the time of primary PCI, later in the hospital stay or shortly after discharge) was not significant (p = 0.64 and p = 0.69 for SAQ AF and SAQ QoL, respectively).

Table 2.

Baseline and 1 year health status outcomes and clinical outcomes

Multivessel n = 251 Culprit-only n = 413 P-Value
Health Status Measures
 SAQ AF score (baseline) 89.6 ± 17.1 89.2 ± 16.8 0.77
 SAQ AF score (1 year) 94.8 ± 14.2 92.8 ± 17.4 0.20
 Mean changes in SAQ AF 5.2 ± 22.4 3.2 ± 20.8 0.34
 SAQ QoL score (baseline) 62.3 ± 20.9 68.5 ± 22.9 < 0.001
 SAQ QoL score (1 year) 85.0 ± 18.3 81.5 ± 20.7 0.07
 Mean changes in SAQ QoL 22.3 ± 24.9 12.7 ± 26.5 < 0.001
Clinical Outcomes at 1 year
 Mortality 8 (3.6%) 14 (3.4%) 0.88
 Recurrent MI 7 (3.5%) 4 (1.4%) 0.12
 Repeat revascularization 17 (7.5%) 32 (9.1%) 0.50
 Severe angina 10 (4.4%) 22 (6.3%) 0.34
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Values are mean ± SD, n (%) or median. AF = angina frequency; MI = myocardial infarction; QoL = quality of life; SAQ = Seattle Angina Questionnaire.

Figure 4. Association of revascularization strategies with health status outcomes.

Figure 4

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The point estimates represent the difference in improvement (from baseline to 1 year) in SAQ AF and SAQ QoL scores and the numbers in parenthesis represent the 95% CI. Estimates (with 95% CI) to the right of the vertical dotted line represent improvement in health status, while those to the left of the vertical dotted line represent decrement in health status. AF = angina frequency; QoL = quality of life; SAQ = Seattle Angina Questionnaire; other abbreviations as in Figure 1.

MULTIVESSEL VERSUS CULPRIT-ONLY REVASCULARIZATION AND CLINICAL OUTCOMES

There was no difference in 1-year mortality between those who did and did not undergo multivessel revascularization (3.6% vs. 3.4%; log-rank test p = 0.88; Table 2 and Online Figure 2). A total 32 patients (9.1%) in the culprit-only group and 17 patients (7.5%) in the multivessel revascularization group underwent further revascularization during 12 months (log-rank test p = 0.50).

SENSITIVITY ANALYSES

When these analyses were repeated in the PCI only cohort, patients who underwent multivessel PCI had significant improvements in health status as compared with culprit-only PCI. The multivariable-adjusted difference in SAQ AF scores was 5.34 points (95% CI 1.77 to 8.92) and in SAQ QoL scores it was 7.78 points (95% CI: 3.79 to 11.77; Figure 4B).

DISCUSSION

To evaluate the health status differences between multivessel and culprit-only revascularization in STEMI patients, we analyzed a multi-center study of contemporary revascularization practice in the U.S. We found that multivessel revascularization was performed in 38% of STEMI patients with MVCAD and that there was modest variation across hospitals. Patient characteristics independently associated with multivessel revascularization included age and a higher number of diseased vessels (Central Illustration). Finally, multivessel revascularization was associated with improvements in both angina and QoL, but not mortality or repeat revascularization procedures, one year after discharge. To our knowledge, this is the first study to evaluate patients’ perception of their symptoms and QoL after complete versus culprit-only revascularization in patients with STEMI and MVCAD and these data extend recent insights from clinical trials of a potential clinical benefit from complete revascularization by also suggesting an improvement in patients’ 1-year health status.

Several recent studies of different revascularization strategies in STEMI patients and MVCAD have been performed (2,25,26), with 2 randomized clinical trials showing better clinical outcomes with complete revascularization (9,10). The PRAMI study compared multivessel (complete) PCI versus culprit-only PCI at time of primary PCI in 465 STEMI patients with MVCAD and found that multivessel PCI lowered the incidence of the primary composite end point of cardiac death, nonfatal myocardial infarction, or refractory angina (hazard ratio [HR]: 0.35; 95% CI: 0.21 to 0.58; p < 0.001) (9). They also reported significantly lower refractory angina (HR: 0.35; 95% CI: 0.18 to 0.69; p = 0.002) and repeat revascularization (HR: 0.30; 95% CI: 0.17 to 0.56; p < 0.001) in the multivessel revascularization group. Another recent randomized trial, CvLPRIT (10), compared a strategy of complete in-hospital revascularization with culprit-only PCI and ischemia-based subsequent revascularization in 296 STEMI patients with MVCAD at time of primary PCI. They found that complete revascularization, including staged in-hospital procedure before discharge, was associated with a lower incidence of death, myocardial infarction, heart failure, or ischemia-driven revascularization at 12 months (10). Our findings extend with these trials by finding less angina and better disease-specific QoL at 1 year, although we were not adequately powered to detect a difference in mortality or subsequent revascularization.

Our study also revealed interesting patterns in the practice of selecting patients with MVCAD for multivessel revascularization during a STEMI hospitalization. We found, among diverse care settings throughout the U.S., that the very old and very young patients were less likely to undergo multivessel revascularization. Similarly, those with a higher number of diseased vessels were more likely to undergo complete revascularization during their hospitalization, rather than at the time of primary reperfusion. Several other factors (e.g., history of prior PCI, troponin level, distribution of culprit vessels) that were significantly different between patients receiving different revascularization strategies were not independently correlated with multivessel revascularization within 6 weeks of an AMI. Unmeasured confounding or selection bias may have influenced our findings since we did not query the clinicians about why complete or culprit-only revascularization was performed. Our findings thus underscore the need for future randomized trials to compare these 2 revascularization strategies and to explicitly measure the effects of treatment strategy on QoL; an outcome of critical importance to patients.

However, the majority of multivessel revascularizations in our study seemed to be driven largely by clinical factors, such as worsening clinical status and anatomic considerations, rather than by presenting sites or physician factors. In fact, the MRR showed only modest variability with only an average 30% variation in the likelihood of receiving multivessel revascularization for a given patient presenting to 1 hospital in our cohort versus another. These variations in care may stem from confusion in the existing literature surrounding the optimal treatment strategy for STEMI patients with MVCAD. Some of this variation might be attributable to the difficulty in interpreting previous studies with different timing and definition of staged and complete revascularization while examining the outcomes of complete revascularization (9,10,25–33) and highlights the opportunity to improve the consistency and quality of care for STEMI patients with MVCAD. Studies excluding staged procedure from either complete or culprit-only groups reported better outcomes in the culprit-only arm (34,35). Conversely, studies considering staged PCI, including staged in-hospital PCI procedures, as a complete revascularization strategy, reported better outcomes with complete revascularization (9,33,36). Congruent with these findings, our definition of staged procedure included all settings in which multivessel revascularization was accomplished either in the hospital or shortly thereafter. Importantly, we found no significant interaction between different strategies of performing multivessel revascularization on outcomes, suggesting similar outcomes with any of the 3 approaches to complete revascularization.

Current guidelines do not recommend revascularization of the non-infarct artery unless indicated by hemodynamic instability or persistent ischemia after PCI of the supposed culprit lesion (3,4) and the clinicians following these patients in the outpatient setting may not recommend intervention for mildly symptomatic STEMI patients. This is supported by our findings that there was not a significantly higher prevalence of severe angina in the culprit-only group. However, patients with multivessel revascularization had a statistically and clinically significant 7-point greater improvement in SAQ QoL as compared with those undergoing culprit-only PCI, even after adjusting for baseline health status and other factors, and a slightly smaller, 4.5-point mean improvement in SAQ AF scores that were larger than those observed in the COURAGE trial (37). One may therefore wonder why patients who have residual angina in the year after AMI might not receive more aggressive anti-anginal therapy or undergo revascularization of their untreated stenosis. While our study cannot provide an explanation for this, there is known to be variability in the quality of follow-up care that may preclude more aggressive treatment of patients’ angina and, given our findings of better angina control and disease-specific QoL, we feel that more complete revascularization at the time of a STEMI might be warranted (38). To definitely prove this, however, randomized trials that systematically measure patients’ health status are needed.

STUDY LIMITATIONS

Our study should be interpreted in the context of several potential limitations. First, in light of the observational nature of our data, it is not possible to establish a causal relationship between multivessel revascularization and improved QoL at 1 year. Patients in our study were likely aware of whether their residual coronary stenoses were fixed or not and this may have influenced their perceptions of recurrent chest pain or perceived QoL. Although these data suggest that health-related QoL is improved with multivessel revascularization in STEMI patients with multivessel coronary disease, unmeasured confounding or selection bias cannot be excluded and may have influenced our findings. Second, we did not query the clinicians as to why complete or culprit-only revascularization was performed and there may have been prognostically important considerations that were not included in our risk-adjusted models. A randomized trial would be needed to remove this confounding, although it is possible that patients in whom the physicians felt complete revascularization would be needed would not enroll such patients.

A third consideration in the interpretation of our findings is that one third of patients were missing SAQ data at 1 year that may have introduced a selection bias, although the rates at which these data were missing did not differ between those with culprit-only and multivessel revascularization. A fourth concern is that an angiographic core laboratory was not used to assess the severity of CAD and angiographic data were obtained by chart abstraction of the dictated reports. Any misclassifications, however, might be expected to bias our study results toward the null. In addition, our secondary analysis of mortality outcomes had limited power to detect any differences in survival. Given the importance of survival, adequately powered randomized clinical trials will be needed to better define the impact of complete revascularization on subsequent mortality. Finally, we excluded patients who did not survive to hospital discharge, and, as such, the observed benefits of multivessel revascularization cannot be extrapolated to extremely sick patients.

CONCLUSIONS

In a large, multicenter AMI registry, we found that multivessel revascularization in the setting of STEMI was common, varied by both patient characteristics and the treating hospital, and was strongly associated with a clinically significant improvement in both angina and QoL 1 year after treatment. Future studies of the potential benefits and harms of multivessel revascularization in STEMI patients should include both symptoms and health-related QoL outcomes so that more complete insights into the benefits of multivessel, as compared with culprit-only, revascularization can be assessed.

Figure 5.

Figure 5

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Central Illustration. Health Status Outcomes after Multivessel Revascularization: Timing of Revascularization and Outcomes

PERSPECTIVES.

Competency in Medical Knowledge

Multivessel revascularization at time of primary percutaneous coronary intervention (PCI) or during index hospitalization in patients with ST-elevation myocardial infarction (STEMI) is associated with better symptom status and quality of life) 1 year later.

Translational Outlook

Additional studies are needed to guide selection of patients with acute STEMI for immediate vs. staged multivessel PCI.

Acknowledgments

Sources of funding: The TRIUMPH study was funded by a grant from the NHLBI (P50 HL 077113) and CV Outcomes (Kansas City, MO).

ABBREVIATIONS

AF

angina frequency

AMI

acute myocardial infarction

CABG

coronary artery bypass grafting

LAD

left anterior descending

MVCAD

Multivessel coronary disease

MRR

median rate ratio

PCI

percutaneous coronary intervention

QoL

quality of life

SAQ

Seattle Angina Questionnaire

STEMI

ST-elevation myocardial infarction

Footnotes

Disclosures:

Dr. John A. Spertus – owns the copyright to the Seattle Angina Questionnaire.

Dr. Ali Shafiq, Dr. Anna Grodzinsky, Dr. Timothy J. Fendler – received support from the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number T32HL110837.

Dr. Amit P. Amin - is funded via a comparative effectiveness research KM1 career development award from the Clinical and Translational Science Award (CTSA) program of the National Center for Advancing Translational Sciences of the National Institutes of Health, Grant Numbers UL1TR000448, KL2TR000450, TL1TR000449 and the National Cancer Institute of the National Institutes of Health, Grant Number 1KM1CA156708-01.

Dr. Jae-Sik Jang - was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIP) (No. R13-2007-023-00000-0).

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