NIHR Signal Treating all narrowed blood vessels immediately after a heart attack may be better than just treating the single blocked artery

Published on 23 March 2016

Coronary angioplasty appears to be more effective in preventing further heart attacks when any other narrowed arteries are also treated at, or shortly after, the main “culprit” artery causing the heart attack is unblocked.

Coronary angioplasty, often with use of a stent to prevent later recurrence, is used to widen blocked or narrowed arteries supplying the heart. This systematic review and meta-analysis found that people with a full thickness heart attack, caused by a culprit artery blockage, and who also had narrowing of other coronary arteries were less likely to have later heart attacks or die from heart disease if they had both problems treated at the same time. Doing multiple-vessel angioplasties may result in about 18 fewer non-fatal heart attacks per 1000 patients treated over two years and 15 fewer deaths due to heart disease per 1000 patients over five years.

This is an area of lively debate among cardiologists, and this review may add evidence to help in this debate. There are other factors to consider before a change to practice or guidelines is contemplated, for instance later planned treatment of other vessels was not evaluated here. However, these results suggest that multi-vessel angioplasty at the same time as primary angioplasty to a culprit lesion is likely safe and effective.

Treating all narrowed blood vessels immediately after a heart attack may be better than just treating the single blocked artery

Why was this study needed?

Around 50,000 men and 32,000 women have a heart attack (myocardial infarction or MI) each year in England. A heart attack occurs when blood supply to the heart muscle is blocked. One of the most common treatments for heart attack is coronary angioplasty, also called percutaneous coronary intervention. This is a procedure that inflates a tiny balloon in the artery to unblock it, usually with insertion of a small tube called a stent, restoring blood flow to the heart. Around 75,000 angioplasties are performed in England each year, though not just for heart attacks.

NICE were unable to advise whether one or multiple vessels should be treated and there are theoretical risks to doing too much at one time, for example kidney problems following the use of dye, stent thrombosis, or bleeding.  So resolving this question could be very useful to patients and the NHS.

What did this study do?

This was an update of an inconclusive 2014 systematic review, and included five randomised controlled trials (two new trials published since 2014) with 1606 participants.

The included trials compared multi-vessel versus culprit-only angioplasty within 12 hours of an acute STEMI heart attack (severe heart attacks where there is complete blockage of blood flow of one or more arteries to the heart) inpatients who had multi-vessel coronary artery disease.

In three of the five studies, angioplasty of all blocked and narrowed arteries was performed during a single procedure. In the largest trial, just the culprit vessel was operated on then two days later the remaining narrowed arteries were treated. In the final study, 64% of patients had all arteries operated on during a single procedure, while the remaining patients had the culprit-vessel operated on first, followed by the others at a later time before being discharged from hospital.

This was a high quality review, and assessment of included trials suggested that they were at low risk of bias. However the number of later heart attacks and deaths are relatively small.

What did it find?

  • Patients having multi-vessel angioplasty were less likely to have another, non-fatal heart attack (relative risk [RR] 0.58, 95% CI 0.36 to 0.93), equivalent to about 18 fewer non-fatal heart attacks per 1000 patients over two years.
  • Multi-vessel angioplasty significantly reduced the risk of death due to heart disease (RR 0.46, 95% CI 0.26 to 0.83), estimated to be 15 fewer deaths due to heart disease per 1000 patients over five years.
  • There was no difference between groups in all-cause mortality or in adverse events.
  • Patients having multi-vessel angioplasty were less likely to have later repeat revascularisation – i.e. to have follow-up angioplasty (relative risk [RR] 0.36, 95% confidence interval [CI] 0.27 to 0.49). It was estimated that multi-vessel angioplasty led to 97 fewer repeat revascularizations per 1000 patients treated over two years.

What does current guidance say on this issue?

NICE guidance from 2013 recommends that coronary angiography (injection of dye into the arteries so that any blockages can be seen on X-ray), should be offered for people with acute STEMI if presented within 12 hours of onset of symptoms. If indicated, they then recommend follow-on angioplasty. The guideline group determined that they were unable to recommend whether the coronary angioplasty should be culprit vessel only or multi-vessel (at the same time or in a staged manner). This was due to insufficient available evidence on the difference between them from a clinical or cost effectiveness perspective. Instead they recommended further research in this area.

What are the implications?

There are some limitations to this study. The events being measured – mortality, repeat non-fatal heart attack and side effects – were infrequent in this group of patients, which can sometimes cause problems with the reliability of meta-analysis.  Taken at face value, the results do suggest that multi-vessel angioplasty can provide appreciable reductions in non-fatal heart attacks, and death due to heart disease; outcomes likely to be of importance to patients.  These benefits may not be seen in smaller, less experienced centres though.

This review did not investigate whether multi-vessel angioplasty performed as a staged procedure within a short time frame may have similar outcomes to immediate angioplasty – these were both included in the multi-vessel intervention. The ongoing COMPLETE trial is comparing ‘staged’ angioplasty of all vessels with culprit only angioplasty and is due to report in 2018.

Citation and Funding

Spencer FA, Sekercioglu N, Prasad M, et al. Culprit vessel versus immediate complete revascularization in patients with ST-segment myocardial infarction-a systematic review. Am Heart J. 2015;170(6):1133-9

No funding information was provided for this study.

Bibliography

Bhatnagar P, Wickramasinghe K, Williams J, et al. The epidemiology of cardiovascular disease in the UK 2014. Heart. 2015;101(15):1182-9.

National Clinical Guideline Centre. Myocardial infarction with ST-segment elevation. Full Guideline. London: National Clinical Guideline Centre; 2013.

NHS Choices. Coronary angioplasty and stent insertion. London: NHS Choices; 2015.

NHS Choices. Heart Attack. London: NHS Choices; 2015.

NICE. Myocardial infarction with ST-segment elevation: acute management. CG167. London: National Institute for Health and Care Excellence; 2013.

Sekercioglu N, Spencer FA, Lopes LC, Guyatt GH. Culprit vessel only vs immediate complete revascularization in patients with acute ST-segment elevation myocardial infarction: systematic review and meta-analysis. Clin Cardiol. 2014;37(12):765-72.

Why was this study needed?

Around 50,000 men and 32,000 women have a heart attack (myocardial infarction or MI) each year in England. A heart attack occurs when blood supply to the heart muscle is blocked. One of the most common treatments for heart attack is coronary angioplasty, also called percutaneous coronary intervention. This is a procedure that inflates a tiny balloon in the artery to unblock it, usually with insertion of a small tube called a stent, restoring blood flow to the heart. Around 75,000 angioplasties are performed in England each year, though not just for heart attacks.

NICE were unable to advise whether one or multiple vessels should be treated and there are theoretical risks to doing too much at one time, for example kidney problems following the use of dye, stent thrombosis, or bleeding.  So resolving this question could be very useful to patients and the NHS.

What did this study do?

This was an update of an inconclusive 2014 systematic review, and included five randomised controlled trials (two new trials published since 2014) with 1606 participants.

The included trials compared multi-vessel versus culprit-only angioplasty within 12 hours of an acute STEMI heart attack (severe heart attacks where there is complete blockage of blood flow of one or more arteries to the heart) inpatients who had multi-vessel coronary artery disease.

In three of the five studies, angioplasty of all blocked and narrowed arteries was performed during a single procedure. In the largest trial, just the culprit vessel was operated on then two days later the remaining narrowed arteries were treated. In the final study, 64% of patients had all arteries operated on during a single procedure, while the remaining patients had the culprit-vessel operated on first, followed by the others at a later time before being discharged from hospital.

This was a high quality review, and assessment of included trials suggested that they were at low risk of bias. However the number of later heart attacks and deaths are relatively small.

What did it find?

  • Patients having multi-vessel angioplasty were less likely to have another, non-fatal heart attack (relative risk [RR] 0.58, 95% CI 0.36 to 0.93), equivalent to about 18 fewer non-fatal heart attacks per 1000 patients over two years.
  • Multi-vessel angioplasty significantly reduced the risk of death due to heart disease (RR 0.46, 95% CI 0.26 to 0.83), estimated to be 15 fewer deaths due to heart disease per 1000 patients over five years.
  • There was no difference between groups in all-cause mortality or in adverse events.
  • Patients having multi-vessel angioplasty were less likely to have later repeat revascularisation – i.e. to have follow-up angioplasty (relative risk [RR] 0.36, 95% confidence interval [CI] 0.27 to 0.49). It was estimated that multi-vessel angioplasty led to 97 fewer repeat revascularizations per 1000 patients treated over two years.

What does current guidance say on this issue?

NICE guidance from 2013 recommends that coronary angiography (injection of dye into the arteries so that any blockages can be seen on X-ray), should be offered for people with acute STEMI if presented within 12 hours of onset of symptoms. If indicated, they then recommend follow-on angioplasty. The guideline group determined that they were unable to recommend whether the coronary angioplasty should be culprit vessel only or multi-vessel (at the same time or in a staged manner). This was due to insufficient available evidence on the difference between them from a clinical or cost effectiveness perspective. Instead they recommended further research in this area.

What are the implications?

There are some limitations to this study. The events being measured – mortality, repeat non-fatal heart attack and side effects – were infrequent in this group of patients, which can sometimes cause problems with the reliability of meta-analysis.  Taken at face value, the results do suggest that multi-vessel angioplasty can provide appreciable reductions in non-fatal heart attacks, and death due to heart disease; outcomes likely to be of importance to patients.  These benefits may not be seen in smaller, less experienced centres though.

This review did not investigate whether multi-vessel angioplasty performed as a staged procedure within a short time frame may have similar outcomes to immediate angioplasty – these were both included in the multi-vessel intervention. The ongoing COMPLETE trial is comparing ‘staged’ angioplasty of all vessels with culprit only angioplasty and is due to report in 2018.

Citation and Funding

Spencer FA, Sekercioglu N, Prasad M, et al. Culprit vessel versus immediate complete revascularization in patients with ST-segment myocardial infarction-a systematic review. Am Heart J. 2015;170(6):1133-9

No funding information was provided for this study.

Bibliography

Bhatnagar P, Wickramasinghe K, Williams J, et al. The epidemiology of cardiovascular disease in the UK 2014. Heart. 2015;101(15):1182-9.

National Clinical Guideline Centre. Myocardial infarction with ST-segment elevation. Full Guideline. London: National Clinical Guideline Centre; 2013.

NHS Choices. Coronary angioplasty and stent insertion. London: NHS Choices; 2015.

NHS Choices. Heart Attack. London: NHS Choices; 2015.

NICE. Myocardial infarction with ST-segment elevation: acute management. CG167. London: National Institute for Health and Care Excellence; 2013.

Sekercioglu N, Spencer FA, Lopes LC, Guyatt GH. Culprit vessel only vs immediate complete revascularization in patients with acute ST-segment elevation myocardial infarction: systematic review and meta-analysis. Clin Cardiol. 2014;37(12):765-72.

Culprit vessel versus immediate complete revascularization in patients with ST-segment myocardial infarction-a systematic review

Published on 19 December 2015

Spencer, F. A.,Sekercioglu, N.,Prasad, M.,Lopes, L. C.,Guyatt, G. H.

Am Heart J Volume 170 , 2015

BACKGROUND: Guidelines suggest percutaneous intervention (PCI) of only the culprit artery in patients presenting with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease. However, recent randomized controlled trials (RCTs) suggest benefit to performing PCI of other stenotic vessels at the same time as culprit vessel PCI. METHODS: We conducted a systematic review with complete case meta-analysis and sensitivity analyses. Data sources included MEDLINE, EMBASE, Cochrane Register of Controlled Trials, and CINAHL from 1946 to March 2014; MEDLINE and EMBASE from March 2014 to March 2015; and scanning of literature for new studies until August 2015. All RCTs comparing multivessel versus culprit-only PCI in patients with STEMI were eligible. The primary outcomes of interest were recurrent myocardial infarction (MI), recurrent revascularization, and mortality. We combined data from trials to estimate the pooled risk ratio (RR) and associated 95% CIs using random-effects models. RESULTS: Five RCTs including 1,606 patients of whom 1,568 had complete data proved eligible. Multivessel revascularization was associated with decreased risk of repeat revascularization (RR 0.36, 95% CI 0.27-0.49, risk difference 9.7% over 2 years) and recurrent nonfatal MI (RR 0.58, 95% CI 0.36-0.93, risk difference 1.8% over 2 years), without increase in mortality (RR 0.82, 95% CI 0.53-1.26) or other adverse events. CONCLUSIONS: Pooled data provide moderate-certainty evidence that performance of multivessel PCI will provide an appreciable reduction in nonfatal MI and high-certainty evidence that it will reduce need for repeat revascularization. Patients are likely to place a high value on these benefits.

Heart attacks are classified by a feature known as the ST segment on the ECG tracing. The ST segment rises with damage to the heart muscle – the higher the ST segment, the greater the damage to the heart.

There are two main types of heart attack: ST segment elevation myocardial infarction (STEMI), and non-ST segment elevation myocardial infarction (NSTEMI).

  • A STEMI is where there is a complete blockage of one or more coronary arteries. This interruption of blood supply causes damage to the section of heart muscle. The severity will depend on the size of the artery and therefore amount of heart muscle affected and also on the length of time that the artery is blocked.
  • An NSTEMI is when one or more coronary arteries are only partially rather than fully blocked. It therefore causes less damage to the heart muscle.

Expert commentary

What is the treating interventionist, faced with multi-vessel primary angioplasty at 3am to make of these data? Unsurprisingly, multi-vessel angioplasty does reduce the need for further revascularisation – this is no surprise – and appears safe, which is surprising. However, there is no mortality benefit and the stated reduction in non-fatal heart attack is tenuous, particularly in contemporary trials. The down-sides include the need for strict adherence to prolonged dual antiplatelet therapy when patient compliance is unknown, higher contrast load and attempting potentially complex coronary intervention in unstable patients when fatigued. Residual ischemia-inducing coronary disease should probably be treated after a heart attack, but a “treat everything at once” strategy may not be superior to culprit-only now with early (days-weeks), staged, physiologically-guided angioplasty later. This is commonly practiced but this strategy was not separately assessed in any of these trials.

Dr Stephen Hoole, Consultant Interventional Cardiologist, Papworth Hospital NHS Foundation Trust, Cambridge

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