"One-Time" versus Staged Multivessel Intervention in Intermediate to Very High-Risk Patients with Non-ST-Segment Elevation Acute Coronary Syndromes

Culprit vessel vs. immediate multivessel vs. out-of-hospital staged intervention for patients with non-ST-segment elevation myocardial infarction and multivessel disease

Background and aims

The optimal interventional strategy remains undetermined in hemodynamically stable patients with NSTEMI and MVD. This study aimed to examine clinical prognosis among culprit vessel, immediate multivessel, and staged percutaneous coronary intervention (PCI) in patients with NSTEMI and MVD.

Methods

This retrospective, observational, single-center study included 943 hemodynamically stable patients with NSTEMI and MVD who had undergone successful drug-eluting stent (DES) implantation from January 2014 to December 2019. Patients were categorized into culprit lesion-only PCI (CL-PCI), immediate multivessel PCI (MV-PCI), and out-of-hospital staged MV-PCI according to PCI strategy. The primary outcome was the composite of major adverse cardiac events (MACEs), including all-cause death, myocardial infarction (MI), or unplanned repeat revascularization. The secondary outcomes were all-cause death, cardiac death, MI, and unplanned repeat revascularization.

Results

Over a median follow-up of 59 months, immediate MV-PCI was associated with a lower risk of all-cause death than CL-PCI (HR: 0.591, 95%CI: 0.364-0.960, P = 0.034). Out-of-hospital staged MV-PCI was associated with a reduced risk of MACE (HR: 0.448, 95%CI: 0.314-0.638, P < 0.001) and all-cause death (HR: 0.326, 95%CI: 0.183-0.584, P < 0.001) compared with CL-PCI. The above results were accordant after multivariate COX analysis and propensity score matching. MACE (HR: 0.560, 95%CI: 0.385-0.813, P = 0.002) and repeat revascularization (HR: 0.627, 95%CI: 0.400-0.982, P = 0.041) were significantly less likely to occur with out-of-hospital MV-PCI rather than immediate MV-PCI. However, the incidences of primary and secondary outcomes were comparable between immediate and staged PCI after confounder adjustment using multivariate regression and propensity score matching analysis. For subgroup analyses stratified by synergy between PCI with taxus and cardiac surgery score, staged MV-PCI was found to lower the risk of MACE compared with immediate MV-PCI in patients with more complex coronary disease.

Conclusion

Hemodynamically stable patients with NSTEMI and MVD benefited from the strategy of MV-PCI. Patients with complex coronary anatomy treated with out-of-hospital staged MV-PCI rather than immediate MV-PCI had lower risks of MACE. These need to be confirmed in the future randomized study.

Effect of Timing of Staged Percutaneous Coronary Intervention on Clinical Outcomes in Patients With Acute Coronary Syndromes

Background

Complete revascularization reduces cardiovascular events in patients with acute coronary syndromes (ACSs) and multivessel disease. The optimal time point of non–target‐vessel percutaneous coronary intervention (PCI) remains a matter of debate. The aim of this study was to investigate the impact of early (<4 weeks) versus late (≥4 weeks) staged PCI of non–target‐vessels in patients with ACS scheduled for staged PCI after hospital discharge.

Methods and Results

All patients with ACS undergoing planned staged PCI from 2009 to 2017 at Bern University Hospital, Switzerland, were analyzed. Patients with cardiogenic shock, in‐hospital staged PCI, staged cardiac surgery, and multiple staged PCIs were excluded. The primary end point was all‐cause death, recurrent myocardial infarction and urgent premature non–target‐vessel PCI. Of 8657 patients with ACS, staged revascularization was planned in 1764 patients, of whom 1432 patients fulfilled the eligibility criteria. At 1 year, there were no significant differences in the crude or adjusted rates of the primary end point (7.8% early versus 10.8% late, hazard ratio [HR], 0.72 [95% CI, 0.47–1.10], P=0.129; adjusted HR, 0.80 [95% CI, 0.50–1.28], P=0.346) and its individual components (all‐cause death: 1.5% versus 2.9%, HR, 0.52 [95% CI, 0.20–1.33], P=0.170; adjusted HR, 0.62 [95% CI, 0.23–1.67], P=0.343; recurrent myocardial infarction: 4.2% versus 4.4%, HR, 0.97 [95% CI, 0.475–1.10], P=0.924; adjusted HR, 1.03 [95% CI, 0.53–2.01], P=0.935; non–target‐vessel PCI, 3.9% versus 5.7%, HR, 0.97 [95% CI, 0.53–1.80], P=0.928; adjusted HR, 1.19 [95% CI, 0.61–2.34], P=0.609).

Conclusions

In this single‐center cohort study of patients with ACS scheduled to undergo staged PCI after hospital discharge, early (<4 weeks) versus late (≥4 weeks) staged PCI was associated with a similar rate of major adverse cardiac events at 1 year follow‐up.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02241291.

Simulation of patient flow in multiple healthcare units using process and data mining techniques for model identification

INTRODUCTION

An approach to building a hybrid simulation of patient flow is introduced with a combination of data-driven methods for automation of model identification. The approach is described with a conceptual framework and basic methods for combination of different techniques. The implementation of the proposed approach for simulation of the acute coronary syndrome (ACS) was developed and used in an experimental study.

METHODS

A combination of data, text, process mining techniques, and machine learning approaches for the analysis of electronic health records (EHRs) with discrete-event simulation (DES) and queueing theory for the simulation of patient flow was proposed. The performed analysis of EHRs for ACS patients enabled identification of several classes of clinical pathways (CPs) which were used to implement a more realistic simulation of the patient flow. The developed solution was implemented using Python libraries (SimPy, SciPy, and others).

RESULTS

The proposed approach enables more a realistic and detailed simulation of the patient flow within a group of related departments. An experimental study shows an improved simulation of patient length of stay for ACS patient flow obtained from EHRs in Almazov National Medical Research Centre in Saint Petersburg, Russia.

CONCLUSION

The proposed approach, methods, and solutions provide a conceptual, methodological, and programming framework for the implementation of a simulation of complex and diverse scenarios within a flow of patients for different purposes: decision making, training, management optimization, and others.

Complete Versus Culprit-Only Revascularization for ST-Segment Elevation Myocardial Infarction and Multivessel Disease in the 2nd Generation Drug-Eluting Stent Era: Data from the INTERSTELLAR Registry

Background and Objectives

We aimed to compare outcomes of complete revascularization (CR) versus culprit-only revascularization for ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) in the 2^nd generation drug-eluting stent (DES) era.

Methods

From 2009 to 2014, patients with STEMI and MVD, who underwent primary percutaneous coronary intervention (PCI) using a 2^nd generation DES for culprit lesions were enrolled. CR was defined as PCI for a non-infarct-related artery during the index admission. Major adverse cardiovascular event (MACE) was defined as cardiovascular (CV) death, non-fatal myocardial infarction, target lesion revascularization, or heart failure during the follow-up year.

Results

In total, 705 MVD patients were suitable for the analysis, of whom 286 (41%) underwent culprit-only PCI and 419 (59%) underwent CR during the index admission. The incidence of MACE was 11.5% in the CR group versus 18.5% in the culprit-only group (hazard ratio [HR], 0.56; 95% confidence interval [CI], 0.37–0.86; p<0.01; adjusted HR, 0.64; 95% CI, 0.40–0.99; p=0.04). The CR group revealed a significantly lower incidence of CV death (7.2% vs. 12.9%; HR, 0.51; 95% CI, 0.31–0.86; p=0.01 and adjusted HR, 0.57; 95% CI; 0.32–0.97; p=0.03, respectively).

Conclusions

CR was associated with better outcomes including reductions in MACE and CV death at 1 year of follow-up compared with culprit-only PCI in the 2^nd generation DES era.