Multivessel Intervention in ST-Segment-Elevation Myocardial Infarction: Evidence-Based Practice or Guesswork?

BACKGROUND: Prior studies on the use of multivessel percutaneous coronary intervention (MV PCI) for patients with STEMI and multivessel coronary artery disease have yielded heterogeneous results. The recent COMPLETE trial demonstrated that MV PCI was superior to culprit-only PCI among patients with STEMI. It is unclear how these trial results apply to clinical decisions encountered in routine practice. METHODS: We studied STEMI admissions among patients >65 years with multivessel disease and CMS-linked data in the NCDR CathPCI Registry® from 7/1/2009–12/31/2017. MV PCI was defined as PCI to a non-culprit lesion ≤45 days of the index procedure. The primary outcome was the composite of death, myocardial infarction, and revascularization from 45 days through 1 year. To account for unmeasured confounders, an instrumental variable analysis (IVA) was used to compare treatment strategies. The instrument was institutional rates of MV PCI. A falsification endpoint of post-discharge major bleeding was utilized to assess for residual confounding. RESULTS: Of 56,332 admissions from 1,102 institutions, 37.7% received MV PCI ≤45 days of index STEMI PCI. Of those undergoing MV PCI, 74.8% received complete revascularization. In unadjusted analysis, MV PCI was associated with a lower cumulative incidence of the composite outcome between 45 days and 1 year (13.9% vs 18.2% for non-MV PCI, p