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.
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.
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.
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