Author + information
- Received June 5, 2018
- Revision received July 24, 2018
- Accepted July 31, 2018
- Published online November 19, 2018.
- Peter T Hu, MDa,b,
- W. Schuyler Jones, MDb,c,
- Thomas J. Glorioso, MSd,e,
- Anna E. Barón, PhDd,e,
- Gary K. Grunwald, PhDd,e,
- Stephen W. Waldo, MDd,f,
- Thomas M. Maddox, MD, MScg,
- Mladen Vidovich, MDh,i,
- Subhash Banerjee, MDj,k and
- Sunil V. Rao, MDb,c,l,∗ ()
- aDepartment of Cardiology, Cleveland Clinic, Cleveland, Ohio
- bDepartment of Medicine, Duke University Medical Center, Durham, North Carolina
- cDuke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
- dDenver Veterans Affairs Medical Center, Denver, Colorado
- eColorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- fSection of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
- gDivision of Cardiology, Washington University, St. Louis, Missouri
- hUniversity of Illinois College of Medicine, Chicago, Illinois
- iJesse Brown Veterans Affairs Medical Center, Chicago, Illinois
- jUniversity of Texas Southwestern Medical Center, Dallas, Texas
- kVeterans Affairs North Texas Health Care System, Dallas, Texas
- lDurham Veterans Affairs Medical Center, Durham, North Carolina
- ↵∗Address for correspondence:
Dr. Sunil V. Rao, Durham VA Medical Center, 508 Fulton Street (111A), Durham, North Carolina 27705.
Objectives The aim of this study was to determine predictors and outcomes associated with staged percutaneous coronary intervention (PCI) versus one-time multivessel revascularization (OTMVR) in patients with multivessel coronary artery disease.
Background Prior observational studies have not evaluated predictors and outcomes of staged PCI versus OTMVR in a heterogenous population of patients with multivessel coronary artery disease who undergo multivessel revascularization.
Methods Data from the Veterans Affairs (VA) CART (Clinical Assessment, Reporting, and Tracking) Program were used to evaluate patients who underwent PCI of >2 vessels between October 1, 2007, and September 3, 2014. Associations between individual factors and the decision to perform staged PCI were assessed. Additionally, the impact of measured patient and procedural factors, site factors, and unmeasured site factors on the decision to perform staged PCI was compared. Cox proportional hazards models were used to determine the association between staged PCI and mortality.
Results A total of 7,599 patients at 61 sites were included. The decision to perform staged PCI was driven by procedural characteristics and unmeasured site factors. Staged PCI was associated with lower risk-adjusted mortality compared with OTMVR (adjusted hazard ratio [HR]: 0.78; 95% confidence interval [CI]: 0.72 to 0.84; p < 0.01). This mortality benefit was observed among the ST-segment elevation myocardial infarction (HR: 0.31; 95% CI: 0.21 to 0.47; p < 0.01), non–ST-segment elevation myocardial infarction (HR: 0.74; 95% CI: 0.64 to 0.87; p < 0.01), unstable angina (HR: 0.75; 95% CI: 0.64 to 0.89; p < 0.01) and stable angina (HR: 0.88; 95% CI: 0.77 to 1.00; p = 0.05) groups.
Conclusions The decision to pursue staged PCI was driven by procedural characteristics and unmeasured site variation and was associated with lower mortality compared with OTMVR. After adjustment, there was an association between staged PCI and reduced mortality. Given the observational nature of these findings, a randomized trial comparing the 2 is needed to guide practice.
- multivessel coronary artery disease
- multivessel coronary revascularization
- one-time multivessel revascularization
- percutaneous coronary intervention
- staged percutaneous coronary intervention
Dr. Jones has received research funding from the Agency for Healthcare Research and Quality, the American Heart Association, AstraZeneca, Bristol-Myers Squibb, Daiichi-Sankyo, and the Patient-Centered Outcomes Research Institute. Dr. Waldo receives unrelated research funding to the Denver Research Institute from Abiomed, Cardiovascular Systems Inc., and Merck Pharmaceuticals. Dr. Maddox was the former director of the VA CART Program. Dr. Vidovich has received research funding from Boston Scientific, Biosensors International, and Sanofi; and is a consultant for Boston Scientific and Abbott and serves on the advisory board for Merit. Dr. Banerjee has received honoraria from Medtronic, Gore, and Cardiovascular Systems Inc., and research funding from Boston Scientific and Merck. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received June 5, 2018.
- Revision received July 24, 2018.
- Accepted July 31, 2018.