Evaluation of different revascularization strategies for patients with acute myocardial infarction with lesions of multiple coronary arteries after primary percutaneous coronary intervention and its economic evaluation

Abstract

To investigate the effect and medical cost of different revascularization strategies for acute myocardial infarction (AMI) patients with multi-vessel disease (MVD). A prospective randomized controlled trial (RCT) was conducted. From January 2009 to June 2012, patients with AMI and MVD undergoing primary percutaneous coronary intervention (PCI) were enrolled. They were randomly assigned to group A [staged PCI for non-infarction related artery (non-IRA) within 7-10 days after AMI] and group B (subsequent PCI for non-IRA recommended only for those with evidence of ischemia). All of patients were given optimized medical therapy according to clinical guideline, and they were followed up for 24 months at regular intervals. Major adverse cardiovascular events (MACE) including recurrence of myocardial infarction and death due to cardiac ailments were recorded. Meanwhile, re-hospitalization from cardiac causes, recurrence of angina, heart failure, and re-PCI, number of stents, total hospital stay days, and total medical expenditure were recorded. A total of 428 patients accomplished the 24-month follow up. All the patients underwent PCI for non-IRA in group A (215 patients), while 62 patients in group B (213 patients) undergone PCI for myocardial ischemia, and 51 patients received non-IRA treatment. There was no significant difference in MACE incidence between group A and group B [8.4% (18/215) vs. 10.8% (23/213), χ² = 0.727, P = 0.394]. The difference of death rate due to cardiac causes (5.1% vs. 6.6%), recurrence of myocardial infarction (4.2% vs. 6.6%), and heart failure (4.2% vs. 7.0%) were not significantly different between groups A and B (all P > 0.05). The rate of recurrence of angina (14.4 % vs. 32.9%), re-hospitalization from cardiac causes (14.4% vs. 33.8%), and re-treatment of implanting stents (12.6% vs. 29.1%) were significantly lower in group A than group B (all P < 0.01), and the rate of revascularization was significantly higher in group A than group B (10.7% vs. 5.2%, P < 0.05). The total number of stents (610 vs. 366), mean number of stents per patient (2.83 ± 0.91 vs. 1.72 ± 0.91, t = 12.725, P = 0.000), and total cost per patient (kRMB: 63.7 ± 12.6 vs. 51.5 ± 1 2.3, t = 10.107, P = 0.000) in group A were significantly higher than those in group B. Total hospital stay days in group A was significantly less than group B (days: 8.21 ± 2.45 vs. 9.89 ± .23, t = 6.071, P = 0.000). Because non-IRA-vascular reconstruction rate was low in group B, the rate of using β-blocker and anti-anginal agents during the 24-month follow up in group B was significantly higher than group A [59.2% (126/213) vs. 47.0% (101/215), χ² = 6.371, P = 0.012; 56.3% (112/213) vs. 17.6% (36/215), χ² = 64.704, P = 0.000]. In patients with AMI and MVD undergone emergency PCI, staged PCI within 7-10 days for non-IRA cannot decrease the incidence of myocardial infarction and death due to cardiac causes, recurrence of angina and rehospitalization for cardiac causes was diminished, and it may increase the number of stents and medical cost significantly.