Complete Revascularization Strategies in ST-Elevation Myocardial Infarction: Real-World Outcomes from a Tertiary care in Pakistan
https://doi.org/10.5281/zenodo.18514613
Keywords:
ST-Segment Elevation Myocardial Infarction; Primary PCI; Multivessel Coronary Artery Disease; Complete Revascularization; Culprit-Only PCI; Major Adverse Cardiovascular Events; Pakistan; Real-World CohortAbstract
Background: Primary PCI saves lives in STEMI, but many patients have significant non-culprit disease left untreated. In a high-volume Pakistani cath-lab, the practical dilemma is whether to “finish the job” during the same admission or accept the risk that staged care may not happen reliably.
Objective: To compare 12-month major adverse cardiovascular events (MACE) between complete revascularization during index hospitalization and culprit-only PCI in STEMI with multivessel CAD.
Methods: This single-center, prospective, registry-embedded cohort enrolled consecutive STEMI patients with angiographically confirmed multivessel CAD (September 1, 2023–February 28, 2024). Patients were classified as complete revascularization (culprit + all treatable non-culprit lesions during the same admission; immediate or staged) versus culprit-only PCI. Here’s the tradeoff we accepted: we chose a real-world cohort (not randomization) because strategy selection was constrained by shock status, contrast/time budget, and cath-lab throughput, so we emphasized prespecified adjusted Cox models and overlap weighting. Primary outcome was 12-month MACE (death, recurrent MI, stroke, HF hospitalization, or ischemia-driven revascularization).
Results: Of 2,146 screened STEMI presentations, 1,702 met criteria (851 per group); 12-month follow-up was available in 1,670/1,702 (98.1%). MACE occurred in 126/851 (14.8%) with complete revascularization vs 167/851 (19.6%) with culprit-only PCI (HR 0.73, 95% CI 0.59–0.90). The association persisted after adjustment (aHR 0.75, 95% CI 0.61–0.92) and overlap weighting (HR 0.74, 95% CI 0.60–0.90). Major bleeding (BARC 3–5) was similar (2.1% vs 1.9%), while contrast-associated AKI was numerically higher with complete revascularization (7.9% vs 5.8%).
Conclusion: In this real-world Pakistani STEMI cohort, complete revascularization during the index hospitalization was associated with lower 12-month MACE than culprit-only PCI, with a modest increase in contrast-related renal risk but no bleeding penalty.
