67 Is it Safe to Send Patients Home for Staged Percutaneous Coronary Intervention (SPCI) to Non-culprit Stenoses Following Primary PCI (PPCI)?

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Abstract

Introduction and aIms

PPCI for acute ST-segment elevation myocardial infarction (STEMI) is the gold-standard treatment. Current guidelines recommend treatment of the culprit vessel only in the acute setting, with elective outpatient sPCI of non-culprit vessels. However, recently published data suggests better outcomes with total revascularisation at the time of PPCI versus culprit vessel revascularisation alone. This total revascularisation strategy has not been compared to a staged approach. We aimed to review the safety and outcomes of our patients undergoing outpatient (OPD) sPCI for non-culprit coronary stenosis following PPCI.

Methods

Using our cardiac database, we identified all patients who had a PPCI and subsequently underwent sPCI.Patient letters and hospital databases were searched to identify firstly, how the clinical decision was made to perform sPCI, secondly, if there were any hospital admissions or cardiac events between discharge from PPCI and admission for OPD sPCI and thirdly, eventual outcomes at sPCI. Patients were excluded if enrolled in any clinical trial evaluating PPCI or if they had in-patient sPCI.

Results

153 patients had a planned sPCI, 11 (7%) were excluded as they underwent in-patient revascularisation for critical or prognostically significant non-culprit disease on PPCI admission. For the remaining 142 patients (16% of PPCI population) the clinical decision pathway for planning sPCI is shown in Table 1. In the majority (80%) this was based primarily on angiographic findings at the time of PPCI.

Results

Cardiac events occurred in 15 patients (11%, all hospital readmissions) prior to sPCI. Five had a new infarct (1 STEMI, 4 NSTEMI) and 10 had troponin negative chest pain. All underwent ‘early’ sPCI. Furthermore, there were no cardiovascular deaths prior to sPCI.

Results

Staged PCI outcomes are shown in Table 2. At sPCI, 114 (80%) patients underwent further PCI/stenting, with 21 patients (15%) requiring treatment of 2 non-culprit vessels. Pressure wire assessment (PW), used to guide intervention in a total of 71 vessels, was negative in 32 vessels thereby preventing unnecessary stenting in 24 patients.

Conclusion

Our data demonstrates that a strategy of elective sPCI following culprit vessel revascularisation in the setting of acute STEMI is associated with a MACE (major adverse cardiac events) of 3.5% (5/142) and a readmission rate of 11% between discharge post PPCI and planned admission for sPCI. Furthermore, at the time of sPCI, 20% of patients required no further intervention potentially avoiding unnecessary stenting compared to a strategy of total revascularisation at time of PPCI where PW was not used and clinical review not possible. Randomised controlled trials, comparing elective sPCI to total revascularisation at the time of PPCI, are required to determine which of these two strategies are best.

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