Temporal Changes and Institutional Variation in Use of Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction With Multivessel Coronary Artery Disease in the United States: An NCDR Research to Practice Project

Eric A Secemsky; Neel Butala; Aishwarya Raja; Rohan Khera; Yongfei Wang; Jeptha P Curtis; Thomas M Maddox; Salim S Virani; Ehrin J Armstrong; Kendrick A Shunk; Ralph G Brindis; Deepak Bhatt; Robert W Yeh

doi:10.1001/jamacardio.2020.5354

. 2020 Nov 4;6(5):574–580. doi: 10.1001/jamacardio.2020.5354

Temporal Changes and Institutional Variation in Use of Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction With Multivessel Coronary Artery Disease in the United States

An NCDR Research to Practice Project

Eric A Secemsky ^1,^2,^3,^✉, Neel Butala ^1,^2,⁴, Aishwarya Raja ¹, Rohan Khera ^5,⁶, Yongfei Wang ^5,⁶, Jeptha P Curtis ^5,⁶, Thomas M Maddox ^7,⁸, Salim S Virani ⁹, Ehrin J Armstrong ¹⁰, Kendrick A Shunk ^11,¹², Ralph G Brindis ^12,¹³, Deepak Bhatt ^2,¹⁴, Robert W Yeh ^1,^2,³

¹Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts

²Harvard Medical School, Boston, Massachusetts

³Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts

⁴Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston

⁵Yale University School of Medicine, New Haven, Connecticut

⁶Yale New Haven Health Services, Center of Outcome and Research Evaluation, New Haven, Connecticut

⁷Division of Cardiology, Washington University School of Medicine, St Louis, Missouri

⁸Healthcare Innovation Lab, BJC HealthCare, Washington University School of Medicine, St Louis, Missouri

⁹Michael E. DeBakey Veterans Affairs Medical Center and Section of Cardiovascular Research, Baylor College of Medicine, Houston, Texas

¹⁰Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver

¹¹Veterans Affairs Medical Center, San Francisco, California

¹²Department of Medicine, University of California, San Francisco, San Francisco

¹³The Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco

¹⁴Brigham and Women's Hospital, Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts

Accepted for Publication: August 27, 2020.

^✉

Corresponding Author: Eric A. Secemsky, MD, MSc, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 375 Longwood Ave, Fourth Floor, Boston, MA 02215 (esecemsk@bidmc.harvard.edu).

Published Online: November 4, 2020. doi:10.1001/jamacardio.2020.5354

Author Contributions: Drs Secemsky and Yeh had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Secemsky, Khera, Virani, Shunk, Brindis, Bhatt, Yeh.

Acquisition, analysis, or interpretation of data: Secemsky, Butala, Raja, Khera, Wang, Curtis, Maddox, Armstrong, Bhatt.

Drafting of the manuscript: Secemsky, Butala, Raja.

Critical revision of the manuscript for important intellectual content: Secemsky, Khera, Wang, Curtis, Maddox, Virani, Armstrong, Shunk, Brindis, Bhatt, Yeh.

Statistical analysis: Secemsky, Khera, Wang, Curtis.

Obtained funding: Secemsky.

Administrative, technical, or material support: Secemsky, Armstrong.

Supervision: Secemsky, Butala, Maddox, Armstrong, Shunk, Yeh.

Other—Initial revisions to the research proposal: Virani.

Conflict of Interest Disclosures: Dr Secemsky reported grants and personal fees from Cook, BD, Medtronic, Philips, and CSI; grants from Boston Scientific and AstraZeneca; personal fees from Janssen and Abbott Vascular outside the submitted work. Dr Butala reported receiving consulting fees from and holding an ownership interest in Hilabs. Dr Curtis reported having a contract with the American College of Cardiology for his role as senior medical officer of the National Cardiovascular Data Registry and receiving salary support from the American College of Cardiology and National Cardiovascular Data Registry, during the conduct of this study; and receiving funding from the Centers for Medicare & Medicaid Services to develop and maintain performance measures that are used for public reporting and holding equity interest in Medtronic outside the submitted work. Dr Maddox discloses current grant funding from the National Center for Advancing Translational Sciences (grant 1U24TR002306-01); current consulting for Creative Educational Concepts Inc and Atheneum Partners; honoraria and/or expense reimbursement in the past 3 years from the University of Utah, NewYork Presbyterian, Westchester Medical Center, Sentara Heart Hospital, the Henry Ford Health System, and the University of California San Diego; current employment as a cardiologist and the executive director of the Healthcare Innovation Lab at BJC HealthCare/Washington University School of Medicine, including advising Myia Labs, for which his employer is receiving equity compensation in the company; and serving as a compensated director for the J. F. Maddox Foundation. Dr Virani reported grants from the Department of Veterans Affairs, World Heart Federation, and the Tahir and Jooma Family; honoraria from the American College of Cardiology as an associate editor for Innovations (acc.org); and participation as a steering committee member Patient and Provider Assessment of Lipid Management (PALM) registry at the Duke Clinical Research Institute (with no financial remuneration) outside the submitted work. Dr Armstrong disclosures consultant/advisory board participation for Abbott Vascular, Boston Scientific, Cardiovascular Systems, Gore, Intact Vascular, Medtronic, and Philips. Dr Shunk disclosed institutional research support from Siemens Medical Systems, Medinol Ltd, Svelte Medical Systems, Cardiovascular Systems Inc, Boston Scientific, and Regeneron Pharmaceuticals Inc; consulting for Terumo, PercAssist, and TransAortic Medical Inc; and equity options in TransAortic Medical and PercAssist. Dr Brindis has a contract with the American College of Cardiology for his role as a senior medical officer in the National Cardiovascular Data Registry. Dr Bhatt reports participation in advisory boards for Cardax, Cereno Scientific, Elsevier Practice Update Cardiology, Medscape Cardiology, PhaseBio, PLx Pharma, Regado Biosciences; on boards of directors for the Boston VA Research Institute, Society of Cardiovascular Patient Care, and TobeSoft; as a chairperson for the American Heart Association Quality Oversight Committee; as a member of data monitoring committees for Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; for the PORTICO trial, funded by St Jude Medical, now Abbott), Cleveland Clinic (including for the ExCEED trial, funded by Edwards), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi Sankyo), and Population Health Research Institute. Dr Bhatt has received honoraria from the American College of Cardiology (senior associate editor, Clinical Trials and News [acc.org]; vice-chair, ACC Accreditation Committee), Baim Institute for Clinical Research (formerly the Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee, funded by Boehringer Ingelheim; AEGIS-II executive committee, funded by CSL Behring), Belvoir Publications (as editor in chief of Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (as editor in chief of Journal of Invasive Cardiology), Journal of the American College of Cardiology (as a guest editor and associate editor), Medtelligence/ReachMD (on continuing medical education steering committees), MJH Life Sciences, Population Health Research Institute (for the COMPASS operations committee, publications committee, and steering committee and as US national coleader; funded by Bayer), Slack Publications (chief medical editor for Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (secretary-treasurer), WebMD (continuing medical education steering committees). In addition, he is involved with Clinical Cardiology (as a deputy editor), the NCDR-ACTION Registry steering committee (as a chair), the VA Clinical Assessment, Reporting and Tracking System for Cath Labs Research and Publications Committee (as a chair); has received research funding from Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Cardax, Chiesi, CSL Behring, Eisai, Ethicon, Ferring Pharmaceuticals, Forest Laboratories/AstraZeneca, Fractyl, Idorsia, Ironwood, Ischemix, Lexicon, Lilly, Medtronic, Pfizer, PhaseBio, PLx Pharma, Regeneron, Roche, Sanofi Aventis, Synaptic, The Medicines Company; has received royalties from Elsevier (editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); served as a site coinvestigator for Biotronik, Boston Scientific, CSI, St Jude Medical (now Abbott), and Svelte; has been a trustee of the American College of Cardiology; has completed unfunded research with FlowCo, Merck, Novo Nordisk, and Takeda; and has received personal fees from Level Ex, Contego Medical, CellProthera, and K2P, outside the submitted work. Dr Yeh reported grants and personal fees from Abbott Vascular, AstraZeneca, Medtronic, and Boston Scientific outside the submitted work. No other disclosures were reported.

Funding/Support: This study was funded by the National Cardiovascular Data Registry. Dr Secemsky is supported by the National Heart, Blood, and Lung Institute (grant K23HL150290).

Role of the Funder/Sponsors: The funding source had no role in the design and conduct of the study. The National Cardiovascular Data Registry manages the collection and management of the data set, but played no role in the analysis and interpretation of the data. The National Cardiovascular Data Registry was also involved in the review and approval of the manuscript, but not the preparation of the manuscript or the decision to submit the manuscript for publication.

^✉

Corresponding author.

PMCID: PMC7643043 PMID: 33146666

Key Points

Question

What are the temporal trends and institutional variation in use of multivessel (MV) percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction?

Findings

In this cohort study of 359 879 patients with ST-elevation myocardial infarction and MV disease in the National Cardiovascular Data Registry CathPCI Registry from the third quarter of 2009 through the first quarter of 2018, MV PCI use increased to 44.0% by the fourth quarter of 2017 and varied across institutions, with a median use of 37.9%.

Meaning

The evidence surrounding MV PCI for patients with ST-elevation myocardial infarction has evolved, along with changes in clinical practice; despite this, MV PCI was used in the minority of patients with ST-elevation myocardial infarction and MV disease, with substantial heterogeneity across institutions in the US.

This cohort study describes temporal trends and institutional variations of multivessel percutaneous coronary intervention use for ST-elevation myocardial infarction in the United States between 2009 and 2018.

Abstract

Importance

After disparate results from observational and small randomized studies, the COMPLETE trial demonstrated superiority of multivessel (MV) percutaneous coronary intervention (PCI) over culprit-only PCI for ST-elevation myocardial infarction (STEMI).

Objective

To describe temporal trends and institutional variation of MV PCI use for STEMI in the United States to inform how new evidence may influence clinical practice.

Design, Setting, and Participants

This cohort study included STEMI admissions involving MV disease from 1598 institutions in the National Cardiovascular Data Registry CathPCI Registry from the third quarter of 2009 to the first quarter of 2018. An MV PCI was defined as a PCI to a nonculprit lesion within 45 days of the index procedure.

Exposures

Multivessel PCI, defined as placement of coronary stents in 2 or more major epicardial vessels or the staged placement of 1 or more coronary stents in a major epicardial vessel distinct from the index culprit vessel, within 45 days of the index PCI.

Main Outcomes and Measures

Outcomes included the proportional use of MV PCI among STEMI admissions with MV disease, and the timing of MV PCI (an index procedure, a staged procedure during index hospitalization, or a postdischarge procedure within 45 days).

Results

Among 359 879 admissions with STEMI and MV disease, MV PCI was performed in 38.5% (n = 138 380; mean [SD] age of patients, 62.3 [12.3] years; 102 266 men [73.9%]) within 45 days. Of those receiving MV PCIs, 30.8% (n = 42 629) had a procedure performed during the index procedure, 31.6% (n = 43 696) as a staged procedure during the index hospitalization, and 37.6% (n = 52 055) within 45 days of discharge. Complete revascularization of all diseased arteries was performed in 76.2% (n = 105 389). From the third quarter of 2009 to the second quarter of 2013, MV PCI use declined by 10%, from 42.7% (3230 of 7572 cases) to a nadir of 32.7% (3386 of 10 342 cases), followed by an increase to 44.0% (5062 of 11 497 cases) by the fourth quarter of 2017. During this time, there was a 13.6% decline in use of postdischarge staged MV PCI (from 23.4% of STEMI cases [1772 of 7572 cases] in the third quarter of 2009 to 9.9% [1094 of 11 171 cases] in the fourth quarter of 2014) and an 12.5% increase in MV PCI performed during the index admission (from 19.3% [1458 of 7572 cases] in the third quarter of 2009 to 31.8% [3557 of 11 171 cases] in the first quarter of 2018). Multivessel PCI use varied substantially across institutions, with a median use of 37.9% (interquartile range, 30.0%-46.5%).

Conclusions and Relevance

In this large, nationwide analysis, MV PCI use for patients with STEMI has been increasing through early 2018 but was used in the minority of patients and with wide variability across US institutions. The adoption of new trial results into guidelines and practice may further promote the growth of MV PCI.

Introduction

More than half of all patients presenting with ST-elevation myocardial infarction (STEMI) have multivessel (MV) disease, which is associated with worse survival rates.¹ These findings have propagated the debate as to whether patients with STEMI and MV disease should undergo MV percutaneous coronary intervention (PCI). Early observational studies and meta-analyses^2,3,4 have suggested that MV PCI was associated with higher mortality rates compared with culprit lesion–only revascularization. This formed the basis of the American College of Cardiology Foundation/American Heart Association STEMI guidelines recommending against routine use of MV PCI.⁵ However, subsequent small randomized clinical trials^6,7,8,9 have demonstrated that MV PCI was associated with a reduction in risk of long-term adverse outcomes. More recently, the Complete versus Culprit-Only Revascularization Strategies to Treat Multivessel Disease after Early PCI for STEMI (COMPLETE) trial,¹⁰ involving 4041 patients, supported these smaller trials, finding that complete revascularization was superior to culprit lesion–only PCI.

Understanding US practice patterns of PCI in patients with STEMI and MV disease is critical to help understand the influence of the growing number of trials evaluating MV PCI, since these studies have the potential to change clinical practice. As a part of the American College of Cardiology Research to Practice Initiative,¹¹ we used data from the National Cardiovascular Data Registry (NCDR) CathPCI Registry to examine temporal trends and institutional variation of use of MV PCI among US patients with STEMI and MV disease.

Methods

We included all admissions from July 1, 2009, to March 30, 2018, in the NCDR CathPCI Registry¹² in which patients received primary PCI for the indication of STEMI within 12 or fewer hours of presentation or PCI within 24 or fewer hours of thrombolysis and had MV disease. Patients were allowed to contribute multiple STEMI admissions as long as each event was 1 year or longer from any prior event. Multivessel disease was defined as 1 or more non–infarct-related artery lesions in a major epicardial vessel 2.5 mm or more in diameter that was distinct from the culprit vessel, with 50% diameter or more stenosis by visual estimation for the left main coronary artery or 70% diameter or more stenosis by visual estimation for all other major epicardial vessels. We excluded admissions from hospitals that only performed STEMI PCI or with less than 10 eligible admissions throughout the study period, admissions of patients with planned surgical revascularization or prior coronary artery bypass grafting, and admissions associated with cardiogenic shock at the start of PCI. A waiver of written informed consent and institutional review board authorization for this study was granted by Advarra Inc.

Multivessel PCI was defined as the placement of coronary stents in 2 or more major epicardial vessels during the index procedure or the staged placement of a coronary stent in a major epicardial vessel distinct from the index culprit vessel 45 days or fewer after the index PCI. We additionally classified MV PCI by timing in association with STEMI as during the index STEMI procedure, a separate staged procedure during the index STEMI hospitalization, or a separate staged procedure postdischarge.

Quarterly time trends of the proportion of patients with STEMI and MV disease receiving MV PCI were examined and stratified by timing of the staged procedures. Randomized trials of MV PCI and society guidelines published during the study period were identified based on the date of online publication. Each institution’s proportional use of MV PCI was depicted in a histogram. We compared patient, procedural, and institutional characteristics among quintiles of institutions with increasing use of MV PCI. Given the large sample size, standardized differences with a 10% or greater difference were used to define significance.¹³ All analyses were performed using SAS 9.4 (SAS Institute) from July 2019 to August 2020.

Results

Among all STEMI admissions (N = 1 022 054), 47.2% (n = 481 995) were associated with multivessel disease and 35.2% (n = 359 879) met criteria to be included in the analysis (eFigure 1 in the Supplement). Multivessel PCI was performed in 38.5% (n = 138 380; mean [SD] age, 62.3 [12.3] years; 102 266 men [73.9%]) within 45 days. Of those receiving MV PCI, 30.8% (n = 42 629) were performed during the index procedure, 31.6% (n = 43 696) as a staged procedure during the index hospitalization, and 37.6% (n = 52 055) within 45 days. The median time from the index PCI to a staged PCI performed during the index hospitalization was 2 (interquartile range [IQR], 2-3) days and a staged postdischarge PCI was 21 (IQR, 12-32) days. Complete revascularization of all diseased arteries was performed in 76.2% (n = 105 389) of those who underwent MV PCI.

Baseline characteristics were similar between admissions of patients when comparing treatment strategies (Table). Procedural characteristics were also well-balanced between those who did not receive MV PCI and those who did, with the exception of the infarct-related artery (eg, left main coronary artery, 381 of 221 499 [0.2%] vs 1391 of 138 380 [1.0%]; left circumflex artery, 31 658 [14.3%] vs 26 461 [19.1%]), stent type (eg, drug-eluting stent: 142 460 [64.3%] vs 111 326 [80.5%]), and number of diseased vessels (eg, 2 vessels only: 156 016 [70.4%] vs 91 157 [65.9%]). Procedural characteristics of the staged MV PCI were overall similar to the index PCI (eTable 1 in the Supplement).

Table. Patient and Procedural Characteristics, Stratified by Treatment With Multivessel Percutaneous Coronary Intervention (PCI).

Description	Multivessel PCI, No. (%)		Standardized difference
Description	No (n = 221 499)	Yes (n = 138 380)	Standardized difference
Age, mean (SD), y	63.8 (12.7)	62.3 (12.3)	9.97
Male	161 169 (72.8)	102 266 (73.9)	−2.97
White race	191 181 (86.3)	121 303 (87.7)	−4.76
BMI, mean (SD)	29.2 (8.8)	29.5 (9.3)	−3.74
Insurance
Private	128 212 (57.9)	84 993 (61.4)	−6.34
Medicare	46 533 (21.0)	25 793 (18.6)	5.21
Medicaid	11 843 (5.4)	7050 (5.1)	0.37
Other	34 911 (15.8)	20 544 (14.9)	2.60
Current smoking	84 839 (38.3)	51 713 (37.4)	2.53
Hypertension	156 939 (70.9)	94 340 (68.2)	5.49
Dyslipidemia	133 800 (60.4)	82 606 (59.7)	1.02
Family history of coronary artery disease	39 079 (17.6)	26 124 (18.9)	−3.72
Prior myocardial infarction	44 438 (20.1)	24 327 (17.6)	6.29
Prior PCI	49 871 (22.5)	26 680 (19.3)	6.68
Estimated glomerular filtration rate, mL/min/1.73 m²
0-29	13 244 (6.0)	5924 (4.3)	7.00
30-59	52 053 (23.5)	30 233 (21.9)	3.67
≥60	156 202 (70.5)	102 223 (73.9)	−6.95
Prior cerebrovascular disease	19 246 (8.7)	9710 (7.0)	5.17
Prior peripheral artery disease	14 610 (6.6)	7088 (5.1)	5.76
Chronic lung disease	22 272 (10.1)	12 170 (8.8)	2.52
Diabetes mellitus	66 548 (30.0)	38 900 (28.1)	4.48
Prior heart failure	11 931 (5.4)	6015 (4.4)	3.92
Cardiomyopathy or left ventricular systolic dysfunction	14 000 (6.3)	8272 (6.0)	−0.25
Cardiac arrest within 24 h	12 447 (5.6)	7797 (5.6)	0.73
Procedure medication
Unfractionated heparin	165 081 (74.5)	103 284 (74.6)	3.25
Bivalirudin	96 193 (43.4)	59 680 (43.1)	−0.95
Glycoprotein IIb/IIIa inhibitor	100 407 (45.3)	63 949 (46.2)	−1.03
Aspirin	200 616 (90.6)	125 957 (91.0)	−1.06
Clopidogrel	113 639 (51.3)	67 285 (48.6)	3.97
Prasugrel	33 899 (15.3)	23 586 (17.0)	−3.57
Ticagrelor	49 275 (22.3)	35 290 (25.5)	−6.40
Radial access	39 684 (17.9)	27 480 (19.9)	−3.37
Femoral/brachial access	181 650 (82.0)	110 813 (80.1)	3.28
Infarct-associated artery
Left main coronary	381 (0.2)	1391 (1.0)	−11.51
Left anterior descending	82 212 (37.1)	50 459 (36.5)	1.13
Left circumflex	31 658 (14.3)	26 461 (19.1)	−13.00
Ramus	1470 (0.7)	1534 (1.1)	−4.42
Right coronary	105 778 (47.8)	58 535 (42.3)	10.98
Facilitated PCI or failed thrombolysis	8859 (4.0)	6637 (4.8)	−5.29
Drug-eluting stent placed	142 460 (64.3)	111 326 (80.5)	−36.90
Bare metal stent placed	59 655 (26.9)	29 020 (21.0)	17.36
Intra-aortic balloon pump	12 582 (5.7)	7883 (5.7)	−1.01
Other mechanical support	1468 (0.7)	1318 (1.0)	−3.68
No. of diseased vessels
2	156 016 (70.4)	91 157 (65.9)	10.56
≥3	65 483 (29.6)	47 223 (34.1)	−10.56
No. of vessels intervened on
1	221 499 (100)	46 621 (33.7)	224.49
2	NA	81 023 (58.6)	NA
≥3	NA	10 736 (7.8)	NA
Complete revascularization	NA	105 389 (76.2)	NA
Multivessel PCI
During index PCI	NA	42 629 (30.8)	NA
In postindex PCI, during index admission	NA	43 696 (31.6)	NA
Postdischarge, within 45 d	NA	52 055 (37.6)	NA
In-hospital outcomes
Myocardial infarction	5034 (2.3)	3154 (2.3)	0.34
Heart failure	8676 (3.9)	5011 (3.6)	1.06
Bleeding or vascular complication or transfusion	15 321 (6.9)	7980 (5.8)	4.48
Acute kidney injury or new need for dialysis	20 469 (9.2)	10 283 (7.4)	5.99
Mortality	9123 (4.1)	3839 (2.8)	6.27
Length of stay, mean (SD), d	3.9 (8.6)	4.0 (8.4)	−1.19
Discharge medications
Angiotensin-converting enzyme inhibitor	126 886 (57.3)	82 726 (59.8)	−5.98
Angiotensin II receptor blocker	20 256 (9.1)	13 352 (9.7)	−1.24
Aspirin	197 243 (89.1)	128 150 (92.6)	−12.18
β Blocker	188 651 (85.2)	122 560 (88.6)	−10.31
Statin	193 380 (87.3)	125 615 (90.8)	−10.66
Clopidogrel	122 321 (55.2)	72 434 (52.3)	5.10
Prasugrel	34 631 (15.6)	26 088 (18.9)	−7.74
Ticagrelor	39 722 (17.9)	30 844 (22.3)	−11.50

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Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); NA, not applicable.

At the beginning of the study (third quarter of 2009), MV PCI was used in 42.7% of multivessel STEMI cases (3230 of 7572 cases; Figure 1).^14,15,16 This rate declined to a nadir of 32.7% (3386 of 10 342 cases) in the second quarter of 2013, corresponding with observational and trial substudies primarily demonstrating no benefit. Rates again increased after the publication of small trials with outcomes supporting MV PCI and peaked by the fourth quarter of 2017 at 44.0% (5062 of 11 497 cases).

The timing of MV PCI also varied over the course of the study period. In the third quarter of 2009, 23.4% of STEMI cases (1772 of 7572) treated with MV PCI occurred during a separate, staged procedure postdischarge. This rate steadily declined to a nadir of 9.9% (1094 of 11 171 cases) in the fourth quarter of 2014, a 13.6% decline. Simultaneously, the frequency of MV PCI being performed during the index STEMI hospitalization increased by 12.5% (from 19.3% [1458 of 7572 cases] in the third quarter of 2009 to 31.8% [3557 of 11 171 cases] in the first quarter of 2018), with MV PCI during the index procedure becoming the dominant strategy by the first quarter of 2018.

Among the 1598 institutions analyzed, the use of MV PCI varied broadly, with a median MV PCI rate of 37.9% and an IQR of 30.0% to 46.5% (Figure 2). Similar variations in MV PCI practice were observed by timing of the nonculprit PCI (eFigure 2 in the Supplement). After stratifying by quintiles of increasing MV PCI use, institutions in the highest quintile had a median use of 54.9% (IQR, 51.1%-60.0%), while institutions in the lowest quintile had a median use of 23.9% (IQR, 19.3%-26.2%). Hospitals in the highest MV PCI quintile had greater annual PCI volumes but similar annual STEMI volumes compared with those in the lowest quintile (eTable 2 in the Supplement). Patient characteristics were mostly similar between institutional quintiles of MV PCI use (eTable 3 in the Supplement).

Discussion

In this study, we found that the use of MV PCI for patients with STEMI varied markedly over time and across hospitals. By early 2018, MV PCI use had increased but was still being used in the minority of patients with STEMI and MV disease. We also observed that the MV PCI strategy changed during this time, with most nonculprit PCIs occurring during the index admission.

Changes in clinical practice appeared to coincide with emerging evidence surrounding MV PCI for STEMI. For instance, there was a sharp decline in use of MV PCI after the publication of multiple observational and trial substudies with negative results.^2,3,4 However, this drop in MV PCI use preceded any formal change in recommendations from society guidelines. Furthermore, following the positive results of the Preventive Angioplasty in Myocardial Infarction (PRAMI) trial⁶ in 2013, MV PCI use began to rise. This was supported by subsequent positive randomized clinical trials.^7,8 By the time the 2015 American College of Cardiology Foundation/American Heart Association/Society for Cardiovascular Angiography & Intervention STEMI PCI guideline¹⁷ was published with an updated recommendation of class IIb, national use had already exceeded 40% and remained close to this level for the remainder of the study period.

Our results have implications for the translation of clinical evidence to real-world practice more broadly. Similar to a study examining real-world trends in use of aspiration thrombectomy,¹⁸ we found that cardiovascular guidelines lagged behind clinician behavior. While it is reassuring that clinicians respond to new data, this rapid change in practice may lead to harm if there is no consensus that these data are sufficient to promote widespread adoption. In addition, the observed variation in use of MV PCI across US institutions suggests that operators interpret and respond to evidence differently. Timely guideline changes are critical to help standardize operator practices and assure that the highest quality of care is being delivered uniformly.

Limitations

Our analysis should be interpreted in the context of its limitations. We examined trends in MV PCI, which is different from the complete revascularization used in the COMPLETE trial.¹⁰ However, 76% of patients with MV PCI in this study received complete revascularization. Furthermore, although CathPCI sites undergo intensive training and random adjudication, these data are self-reported and may be subject to misclassification.

Conclusions

In conclusion, we found in this large, nationwide analysis that MV PCI use for patients with STEMI was increasing through early 2018 but being performed in a minority of patients and with wide variability across the US. We anticipate that the continued adoption of new trial results into guidelines and practice may further promote the growth of MV PCI.

Supplement.

eFigure 1. Flow Diagram of Patient Cohort Included in Study

eFigure 2. Institutional Variation in Timing of Non-Culprit PCI among ST-Segment Elevation Myocardial Infarction Admissions Associated with Multivessel Disease

eTable 1. Procedural Characteristics of Staged Multivessel Percutaneous Coronary Intervention after Index Percutaneous Coronary Intervention

eTable 2. Institutional Characteristics, Stratified by Institutional Quintile of Use of Multivessel Percutaneous Coronary Intervention

eTable 3. Patient and Procedural Characteristics, Stratified by Institutional Quintile of Use of Multivessel Percutaneous Coronary Intervention

Click here for additional data file.^{(448.9KB, pdf)}

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4.Hannan EL, Samadashvili Z, Walford G, et al. Culprit vessel percutaneous coronary intervention versus multivessel and staged percutaneous coronary intervention for ST-segment elevation myocardial infarction patients with multivessel disease. JACC Cardiovasc Interv. 2010;3(1):22-31. doi: 10.1016/j.jcin.2009.10.017 [DOI] [PubMed] [Google Scholar]
5.O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(4):e78-e140. doi: 10.1016/j.jacc.2012.11.019 [DOI] [PubMed] [Google Scholar]
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7.Gershlick AH, Khan JN, Kelly DJ, et al. Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel disease: the CvLPRIT trial. J Am Coll Cardiol. 2015;65(10):963-972. doi: 10.1016/j.jacc.2014.12.038 [DOI] [PMC free article] [PubMed] [Google Scholar]
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10.Mehta SR, Wood DA, Storey RF, et al. ; COMPLETE Trial Steering Committee and Investigators . Complete revascularization with multivessel PCI for myocardial infarction. N Engl J Med. 2019;381(15):1411-1421. doi: 10.1056/NEJMoa1907775 [DOI] [PubMed] [Google Scholar]
11.Maddox TM, Masoudi FA, Oetgen WJ, Rumsfeld JS. The capacity of evidence to inform practice: the Rapid Registry Response (RRR) initiative. J Am Coll Cardiol. 2015;65(20):2252-2253. doi: 10.1016/j.jacc.2015.04.007 [DOI] [PubMed] [Google Scholar]
12.Brindis RG, Fitzgerald S, Anderson HV, Shaw RE, Weintraub WS, Williams JF. The American College of Cardiology–National Cardiovascular Data Registry (ACC-NCDR): building a national clinical data repository. J Am Coll Cardiol. 2001;37(8):2240-2245. doi: 10.1016/S0735-1097(01)01372-9 [DOI] [PubMed] [Google Scholar]
13.Austin PC. Using the standardized difference to compare the prevalence of a binary variable between two groups in observational research. Communications in Statistics–Simulation and Computation. 2009;38(6):1228-1234. doi: 10.1080/03610910902859574 [DOI] [Google Scholar]
14.Politi L, Sgura F, Rossi R, et al. A randomised trial of target-vessel versus multi-vessel revascularisation in ST-elevation myocardial infarction: major adverse cardiac events during long-term follow-up. Heart. Correction published in Heart. 2014;100(4):350. 2010;96(9):662-667. doi: 10.1136/hrt.2009.177162 [DOI] [PubMed] [Google Scholar]
15.Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. Correction published in Circulation. 2012;125(8):e412. 2011;124(23):e574-e651. doi: 10.1161/CIR.0b013e31823ba622 [DOI] [PubMed] [Google Scholar]
16.Ibanez B, James S, Agewall S, et al. ; ESC Scientific Document Group . 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119-177. doi: 10.1093/eurheartj/ehx393 [DOI] [PubMed] [Google Scholar]
17.Levine GN, Bates ER, Blankenship JC, et al. 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-Elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. J Am Coll Cardiol. 2016;67(10):1235-1250. doi: 10.1016/j.jacc.2015.10.005 [DOI] [PubMed] [Google Scholar]
18.Secemsky EA, Ferro EG, Rao SV, et al. Association of physician variation in use of manual aspiration thrombectomy with outcomes following primary percutaneous coronary intervention for ST-elevation myocardial infarction: the National Cardiovascular Data Registry CathPCI Registry. JAMA Cardiol. 2019;4(2):110-118. doi: 10.1001/jamacardio.2018.4472 [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement.

eFigure 1. Flow Diagram of Patient Cohort Included in Study

eFigure 2. Institutional Variation in Timing of Non-Culprit PCI among ST-Segment Elevation Myocardial Infarction Admissions Associated with Multivessel Disease

eTable 1. Procedural Characteristics of Staged Multivessel Percutaneous Coronary Intervention after Index Percutaneous Coronary Intervention

eTable 2. Institutional Characteristics, Stratified by Institutional Quintile of Use of Multivessel Percutaneous Coronary Intervention

eTable 3. Patient and Procedural Characteristics, Stratified by Institutional Quintile of Use of Multivessel Percutaneous Coronary Intervention

Click here for additional data file.^{(448.9KB, pdf)}

[hbr200028r1] 1.Park DW, Clare RM, Schulte PJ, et al. Extent, location, and clinical significance of non-infarct-related coronary artery disease among patients with ST-elevation myocardial infarction. JAMA. 2014;312(19):2019-2027. doi: 10.1001/jama.2014.15095 [DOI] [PubMed] [Google Scholar]

[hbr200028r2] 2.Vlaar PJ, Mahmoud KD, Holmes DR Jr, et al. Culprit vessel only versus multivessel and staged percutaneous coronary intervention for multivessel disease in patients presenting with ST-segment elevation myocardial infarction: a pairwise and network meta-analysis. J Am Coll Cardiol. 2011;58(7):692-703. doi: 10.1016/j.jacc.2011.03.046 [DOI] [PubMed] [Google Scholar]

[hbr200028r3] 3.Toma M, Buller CE, Westerhout CM, et al. ; APEX-AMI Investigators . Non-culprit coronary artery percutaneous coronary intervention during acute ST-segment elevation myocardial infarction: insights from the APEX-AMI trial. Eur Heart J. 2010;31(14):1701-1707. doi: 10.1093/eurheartj/ehq129 [DOI] [PubMed] [Google Scholar]

[hbr200028r4] 4.Hannan EL, Samadashvili Z, Walford G, et al. Culprit vessel percutaneous coronary intervention versus multivessel and staged percutaneous coronary intervention for ST-segment elevation myocardial infarction patients with multivessel disease. JACC Cardiovasc Interv. 2010;3(1):22-31. doi: 10.1016/j.jcin.2009.10.017 [DOI] [PubMed] [Google Scholar]

[hbr200028r5] 5.O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(4):e78-e140. doi: 10.1016/j.jacc.2012.11.019 [DOI] [PubMed] [Google Scholar]

[hbr200028r6] 6.Wald DS, Morris JK, Wald NJ, et al. ; PRAMI Investigators . Randomized trial of preventive angioplasty in myocardial infarction. N Engl J Med. 2013;369(12):1115-1123. doi: 10.1056/NEJMoa1305520 [DOI] [PubMed] [Google Scholar]

[hbr200028r7] 7.Gershlick AH, Khan JN, Kelly DJ, et al. Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel disease: the CvLPRIT trial. J Am Coll Cardiol. 2015;65(10):963-972. doi: 10.1016/j.jacc.2014.12.038 [DOI] [PMC free article] [PubMed] [Google Scholar]

[hbr200028r8] 8.Engstrøm T, Kelbæk H, Helqvist S, et al. ; DANAMI-3—PRIMULTI Investigators . Complete revascularisation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multivessel disease (DANAMI-3–PRIMULTI): an open-label, randomised controlled trial. Lancet. 2015;386(9994):665-671. doi: 10.1016/S0140-6736(15)60648-1 [DOI] [PubMed] [Google Scholar]

[hbr200028r9] 9.Smits PC, Abdel-Wahab M, Neumann F-J, et al. ; Compare-Acute Investigators . Fractional flow reserve-guided multivessel angioplasty in myocardial infarction. N Engl J Med. 2017;376(13):1234-1244. doi: 10.1056/NEJMoa1701067 [DOI] [PubMed] [Google Scholar]

[hbr200028r10] 10.Mehta SR, Wood DA, Storey RF, et al. ; COMPLETE Trial Steering Committee and Investigators . Complete revascularization with multivessel PCI for myocardial infarction. N Engl J Med. 2019;381(15):1411-1421. doi: 10.1056/NEJMoa1907775 [DOI] [PubMed] [Google Scholar]

[hbr200028r11] 11.Maddox TM, Masoudi FA, Oetgen WJ, Rumsfeld JS. The capacity of evidence to inform practice: the Rapid Registry Response (RRR) initiative. J Am Coll Cardiol. 2015;65(20):2252-2253. doi: 10.1016/j.jacc.2015.04.007 [DOI] [PubMed] [Google Scholar]

[hbr200028r12] 12.Brindis RG, Fitzgerald S, Anderson HV, Shaw RE, Weintraub WS, Williams JF. The American College of Cardiology–National Cardiovascular Data Registry (ACC-NCDR): building a national clinical data repository. J Am Coll Cardiol. 2001;37(8):2240-2245. doi: 10.1016/S0735-1097(01)01372-9 [DOI] [PubMed] [Google Scholar]

[hbr200028r13] 13.Austin PC. Using the standardized difference to compare the prevalence of a binary variable between two groups in observational research. Communications in Statistics–Simulation and Computation. 2009;38(6):1228-1234. doi: 10.1080/03610910902859574 [DOI] [Google Scholar]

[hbr200028r14] 14.Politi L, Sgura F, Rossi R, et al. A randomised trial of target-vessel versus multi-vessel revascularisation in ST-elevation myocardial infarction: major adverse cardiac events during long-term follow-up. Heart. Correction published in Heart. 2014;100(4):350. 2010;96(9):662-667. doi: 10.1136/hrt.2009.177162 [DOI] [PubMed] [Google Scholar]

[hbr200028r15] 15.Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. Correction published in Circulation. 2012;125(8):e412. 2011;124(23):e574-e651. doi: 10.1161/CIR.0b013e31823ba622 [DOI] [PubMed] [Google Scholar]

[hbr200028r16] 16.Ibanez B, James S, Agewall S, et al. ; ESC Scientific Document Group . 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119-177. doi: 10.1093/eurheartj/ehx393 [DOI] [PubMed] [Google Scholar]

[hbr200028r17] 17.Levine GN, Bates ER, Blankenship JC, et al. 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-Elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. J Am Coll Cardiol. 2016;67(10):1235-1250. doi: 10.1016/j.jacc.2015.10.005 [DOI] [PubMed] [Google Scholar]

[hbr200028r18] 18.Secemsky EA, Ferro EG, Rao SV, et al. Association of physician variation in use of manual aspiration thrombectomy with outcomes following primary percutaneous coronary intervention for ST-elevation myocardial infarction: the National Cardiovascular Data Registry CathPCI Registry. JAMA Cardiol. 2019;4(2):110-118. doi: 10.1001/jamacardio.2018.4472 [DOI] [PMC free article] [PubMed] [Google Scholar]

PERMALINK

Temporal Changes and Institutional Variation in Use of Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction With Multivessel Coronary Artery Disease in the United States

Eric A Secemsky, MD

Neel Butala, MD

Aishwarya Raja, BSc

Rohan Khera, MD

Yongfei Wang, MS

Jeptha P Curtis, MD

Thomas M Maddox, MD

Salim S Virani, MD, PhD

Ehrin J Armstrong, MD

Kendrick A Shunk, MD, PhD

Ralph G Brindis, MD

Deepak Bhatt, MD

Robert W Yeh, MD

Key Points

Question

Findings

Meaning

Abstract

Importance

Objective

Design, Setting, and Participants

Exposures

Main Outcomes and Measures

Results

Conclusions and Relevance

Introduction

Methods

Results

Table. Patient and Procedural Characteristics, Stratified by Treatment With Multivessel Percutaneous Coronary Intervention (PCI).

Figure 1. Temporal Trends in Timing of Multivessel (MV) Percutaneous Coronary Intervention (PCI) for ST-Segment Elevation Myocardial Infarction (STEMI).

Figure 2. Institutional Use of Multivessel Percutaneous Coronary Intervention Among ST-Elevation Myocardial Infarction Admissions Associated With Multivessel Disease.

Discussion

Limitations

Conclusions

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

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