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Bangalore S, Toklu B, Wetterslev J. Complete Versus Culprit-Only Revascularization for ST-Segment–Elevation Myocardial Infarction and Multivessel Disease. Circ Cardiovasc Interv 2015; 8:CIRCINTERVENTIONS.114.002142. [DOI: 10.1161/circinterventions.114.002142] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The 2013 American College of Cardiology Foundation/American Heart Association guidelines for patients with ST-segment–elevation myocardial infarction gives a class III indication for nonculprit artery percutaneous coronary intervention at the time of primary percutaneous coronary intervention, driven by data from observational studies. However, more recent trials suggest otherwise.
Methods and Results—
We conducted PUBMED, EMBASE, and CENTRAL searches for randomized trials comparing complete versus culprit-only revascularization in patients with ST-segment–elevation myocardial infarction. Efficacy outcomes were major adverse cardiovascular events, as well as death, cardiovascular death, myocardial infarction, and repeat revascularization. Safety outcomes were contrast-induced nephropathy, contrast volume used, and procedure time. Five trials with 1165 patients fulfilled the inclusion criteria. Complete revascularization (68% during index percutaneous coronary intervention) was associated with significant reduction in major adverse cardiovascular events (rate ratio =0.48; 95% confidence interval =0.37–0.61), death (rate ratio =0.60; 95% confidence interval =0.38–0.97), cardiovascular death (rate ratio =0.38, 95% confidence interval =0.20–0.73), and repeat revascularization (rate ratio =0.42; 95% confidence interval =0.31–0.57) when compared with culprit-only revascularization. However, trial sequential analyses (similar to interim analysis of a randomized trial) powered for a 25% relative reduction showed firm evidence (cumulative z-curve crossed the monitoring boundary) only for major adverse cardiovascular events driven by a decrease in repeat revascularization with no firm evidence for reduction in death and myocardial infarction. Moreover, there was a significant increase in contrast volume use (mean difference 85.12 [70.41–83.00] ml) and procedure time (mean difference 16.42 [13.22–19.63] mins) with complete revascularization without increase in contrast-induced nephropathy.
Conclusions—
In patients with ST-segment–elevation myocardial infarction, immediate or staged complete revascularization results in significant reduction in major adverse cardiovascular events driven largely by reduction in repeat revascularization with no firm evidence for the reduction in death or myocardial infarction when compared with culprit-only revascularization.
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Affiliation(s)
- Sripal Bangalore
- From the Division of Cardiology, New York University School of Medicine, New York, NY (S.B., B.T.); and Division of Cardiology, The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (J.W.)
| | - Bora Toklu
- From the Division of Cardiology, New York University School of Medicine, New York, NY (S.B., B.T.); and Division of Cardiology, The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (J.W.)
| | - Jørn Wetterslev
- From the Division of Cardiology, New York University School of Medicine, New York, NY (S.B., B.T.); and Division of Cardiology, The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (J.W.)
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Park H, Hong YJ, Rhew SH, Kim SS, Jeong YW, Jeong HC, Cho JY, Jang SY, Lee KH, Park KH, Sim DS, Yoon NS, Yoon HJ, Kim KH, Park HW, Kim JH, Ahn Y, Jeong MH, Cho JG, Park JC. Effect of revascularization strategy in patients with acute myocardial infarction and renal insufficiency with multivessel disease. Korean J Intern Med 2015; 30:177-90. [PMID: 25750559 PMCID: PMC4351324 DOI: 10.3904/kjim.2015.30.2.177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 05/27/2014] [Accepted: 06/13/2014] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS The aim of this study was to compare the risk of complications and outcome between infarct-related artery (IRA)-only revascularization and multivessel (MV) revascularization in patients with acute myocardial infarction (MI) with renal insufficiency and MV disease. METHODS A total of 1,031 acute MI patients with renal insufficiency and MV disease who were registered in the Korea Working Group on Myocardial Infarction were enrolled. They were divided into two groups (IRA-only revascularization group, n = 404; MV revascularization group, n = 627), and investigated the cumulative incidence of major adverse cardiac events (MACE) and the incidence of complications after percutaneous coronary intervention (PCI). RESULTS Complications after PCI occurred in 19.9% of all patients (206/1,031). Complications after PCI occurred more frequently in the MV revascularization group compared with the IRA-only revascularization group (20.1% [126/627] vs. 15.3% [62/404], respectively; p = 0.029]. The overall in-hospital mortality rate was 6.3%, and there was no significant difference between the groups (5.2% in the IRA-only revascularization group vs. 7.0% in the MV revascularization group; p = 0.241). The total incidence of MACE was 11.1%, and there was no significant difference between the groups (11.6% in the IRA-only revascularization group vs. 10.7% in the MV revascularization group; p = 0.636). CONCLUSIONS The incidence of complications after PCI was significantly lower in the IRA-only revascularization group compared with the MV revascularization group. However, there were no significant difference in the 12-month outcomes between groups in patients with acute MI and renal insufficiency with MV disease.
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Affiliation(s)
- Hyukjin Park
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital and Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Young Joon Hong
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital and Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Si Hyun Rhew
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital and Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Sung Soo Kim
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital and Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Young Wook Jeong
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital and Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Hae Chang Jeong
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital and Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Jae Yeong Cho
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital and Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Soo Young Jang
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital and Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Ki Hong Lee
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital and Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Keun Ho Park
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital and Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Doo Sun Sim
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital and Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Nam Sik Yoon
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital and Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Hyun Ju Yoon
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital and Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Kye Hun Kim
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital and Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Hyung Wook Park
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital and Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Ju Han Kim
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital and Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Youngkeun Ahn
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital and Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Myung Ho Jeong
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital and Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Jeong Gwan Cho
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital and Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Jong Chun Park
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital and Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
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Abstract
Congestive heart failure (CHF) remains a significant cause of death and disability in industrialized countries. Projections show that the prevalence of CHF will increase 46% from 2012 to 2030, resulting in over eight million adults with CHF in the United States. While substantial advances have been achieved in the treatment of CHF over the past two decades, CHF rivals cancer as a cause of mortality. Strategies focused on prevention of CHF should be emphasized to meaningfully impact the projected increase in CHF. Irrespective of the type of CHF, either systolic or diastolic, coronary artery disease has supplanted hypertension as the most prevalent cause for congestive heart failure, with a high rate of mortality and future hospitalizations. Since coronary artery disease plays a central role in the development of CHF, approaches to treat coronary artery disease and identification of patients at risk for recurrent myocardial infarction (RMI) are approaches to prevent development of CHF. Subjects who sustain recurrent MI represent a particularly high-risk group for development of CHF. Despite the evolution of therapy for MI from thrombolytic therapy to primary percutaneous coronary intervention (PCI), RMI occurs in ~ 10% of patients in the first year after first MI, and 3 years after their first MI. In this review I explore emerging approaches to prevent RMI including the rationale for recent trials of complete revascularization at the time of MI, newly emerging biomarkers that have additive predictive value for identifying patients with high risk of CHF and death when using existing biomarkers. Finally, the paradigm of hematopoietic stem cell mobilization in MI leading to monocyte expansion and acceleration of atherosclerosis is discussed as an emerging approach to identify patients at high risk of RMI, CHF, and death after MI.
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Elbarouni B, Cantor WJ, Ducas J, Borgundvaag B, Džavík V, Heffernan M, Buller CE, Langer A, Goodman SG, Yan AT. Efficacy of an early invasive strategy after fibrinolysis in ST-elevation myocardial infarction relative to the extent of coronary artery disease. Can J Cardiol 2014; 30:1555-61. [PMID: 25475460 DOI: 10.1016/j.cjca.2014.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 09/02/2014] [Accepted: 09/02/2014] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND A strategy of early transfer for coronary angiography and intervention is superior to a standard approach of delayed coronary angiography after fibrinolysis for ST-elevation myocardial infarction (STEMI). STEMI patients with lesions in noninfarct-related arteries have a worse prognosis compared with patients with single vessel disease. This study aimed to assess whether the benefits of an early invasive strategy differ in patients with single vessel and multivessel disease. METHODS The Trial of Routine ANgioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI) randomized STEMI patients receiving fibrinolysis to a strategy of early transfer and coronary angiography vs a standard approach. In this post hoc analysis, we stratified 992 patients into 2 groups according to the presence or absence of multivessel disease. We compared the 2 groups in terms of baseline characteristics, in-hospital management, and patient outcomes, and tested for treatment heterogeneity. RESULTS Multivessel disease was present in 369 (37%) patients. Patients with multivessel disease had a greater rate of the primary composite end point of in-hospital death, recurrence of infarction, recurrent ischemia, shock, or heart failure at 30 days (18.2% vs 10.8%; P < 0.001). An early invasive strategy was efficacious in both groups for the primary outcome. In multivariable analysis adjusting for Global Registry of Acute Coronary Events (GRACE) risk score, there was no significant treatment heterogeneity (all P interaction > 0.40) for the primary end point, or death/recurrence of infarction at 6 months and 1 year. CONCLUSIONS Multivessel disease is present in a significant proportion of STEMI patients treated with fibrinolysis and is associated with worse outcomes. A strategy of early transfer and coronary intervention after fibrinolysis was beneficial regardless of the presence or absence of multivessel disease.
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Affiliation(s)
- Basem Elbarouni
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; St Boniface General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Warren J Cantor
- Southlake Regional Health Centre, Newmarket, University of Toronto, Toronto, Ontario, Canada
| | - John Ducas
- St Boniface General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Vladimír Džavík
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Christopher E Buller
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Anatoly Langer
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Shaun G Goodman
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Andrew T Yan
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
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Tusun E, Uluganyan M, Ugur M, Karaca G, Osman F, Koroglu B, Murat A, Ekmekci A, Uyarel H, Sahin O, Eren M, Bolca O. ST-segment elevation of right precordial lead (V4 R) is associated with multivessel disease and increased in-hospital mortality in acute anterior myocardial infarction patients. Ann Noninvasive Electrocardiol 2014; 20:362-7. [PMID: 25209301 DOI: 10.1111/anec.12199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND ST segment elevation of chest lead V4 R is associated with worse prognosis in acute inferior ST-elevation myocardial infarction (STEMI). This study tried to determine the relationship between ST elevation in the right precordial lead V4 R and acute anterior STEMI. METHODS Prospective study of 144 consecutive anterior STEMI patients: all had 15-lead ECG recordings (12 conventional leads and V3 R-V5 R) obtained. Patients were classified into two groups on the basis of presence (Group I, 50 patients) or absence (Group II, 94 patients) of ST-segment elevation ≥0.5 mm in lead V4 R. RESULTS Multivessel involvement was significantly higher in Group I compared with Group II (54% and 23% respectively, P < 0.001). Major adverse cardiac events and in-hospital mortality was also significantly higher for those in Group I (P < 0.02 for both). A significant correlation was found between in-hospital mortality and those in Group I (P = 0.03, OR: 6.27, CI: 1.22-32.3). There was an independent relationship between in-hospital mortality and V4 R-ST elevation (P = 0.03, OR: 11.64, CI: 1.3-27.4). CONCLUSION ST segment elevation in chest lead V4 R is associated with multivessel disease and increased in-hospital mortality in patients with anterior STEMI that had undergone primary percutaneous coronary intervention to the left anterior descending artery.
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Affiliation(s)
- Eyyup Tusun
- Clinic of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Center Training and Research Hospital, Istanbul, Turkey
| | - Mahmut Uluganyan
- Clinic of Cardiology, Kadirli Government Hospital, Osmaniye, Turkey
| | - Murat Ugur
- Clinic of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Center Training and Research Hospital, Istanbul, Turkey
| | - Gurkan Karaca
- Clinic of Cardiology, Osmancik Government Hospital, Corum, Turkey
| | - Faizel Osman
- Department of Cardiology, University Hospital Coventry, Coventry, United Kingdom
| | - Bayram Koroglu
- Clinic of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Center Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Murat
- Clinic of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Center Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Ekmekci
- Clinic of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Center Training and Research Hospital, Istanbul, Turkey
| | - Hüseyin Uyarel
- Clinic of Cardiology, Bezmialem University Hospital, Istanbul, Turkey
| | - Osman Sahin
- Clinic of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Center Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Eren
- Clinic of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Center Training and Research Hospital, Istanbul, Turkey
| | - Osman Bolca
- Clinic of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Center Training and Research Hospital, Istanbul, Turkey
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de Paula JGR, de Godoy MF, dos Santos MA, Pivatelli FC, Osti AVG, Trindade LF, Novelli D, Nakazone MA. Management of multivessel coronary disease after primary angioplasty: staged reintervention versus optimized clinical treatment and two-year follow-up. Braz J Cardiovasc Surg 2014; 29:177-85. [PMID: 25140467 PMCID: PMC4389456 DOI: 10.5935/1678-9741.20140051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 02/26/2014] [Indexed: 11/20/2022] Open
Abstract
Objective In the clinical scenario of ST-segment elevation acute myocardial infarction,
several patients with multivessel coronary atherosclerotic disease are discharged
without a defined strategy to monitor the residual atherosclerotic lesions. The
clinical endpoints evaluated were cardiovascular death, symptoms of angina
pectoris, rehospitalization for a new acute coronary syndrome, and the necessity
of reintervention during the two-year follow-up. Methods This observational, prospective, and historical study included multivessel
coronary atherosclerotic disease patients who were admitted to a tertiary care
university hospital with ST-segment elevation acute myocardial infarction and
underwent primary percutaneous coronary intervention with stent implantation only
at the culprit lesion site; these patients were monitored in the outpatient clinic
according to two treatments: the Clinical Group - CG (optimized pharmacological
therapy associated with counseling for a healthy diet and cardiac rehabilitation)
or the Intervention Group - IG (new staged percutaneous coronary intervention or
surgical coronary artery bypass graft surgery combined with the previously
prescribed treatment). Results Of 143 patients consecutively admitted with ST-segment elevation acute myocardial
infarction, 57 were eligible for the study (CG=44 and IG=13). Regarding the
clinical endpoints, the cardiovascular death rate did not differ between the CG
and IG. The symptom of angina pectoris and the rehospitalization rate for a new
episode of acute coronary syndrome were accentuated in the CG
(P=0.020 and P=0.049, respectively) mainly in
individuals with evidence of ischemia evidenced by myocardial scintigraphy
(P<0.001 and P=0.001, respectively) which
culminated in an even greater need for reintervention (P=0.001)
in this subgroup of patients. Conclusion The staged intervention was demonstrated to be safe and able to reduce angina
pectoris and rehospitalization for a new episode of acute coronary syndrome. In
addition, it decreases the likelihood of unplanned reinterventions of patients
without ischemia evidenced by myocardial scintigraphy.
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Affiliation(s)
- José Guilherme Rodrigues de Paula
- Correspondence address: José Guilherme Rodrigues de Paula, Hospital de
Base de S. José do Rio Preto - Laboratório de Hemodinâmica e Cardiologia
Intervencionista, Av. Brigadeiro Faria Lima, 5544, São José do Rio Preto, SP, Brazil,
Zip code: 15090-000. E-mail:
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[ST segment elevation myocardial infarction: what is the best timing for revascularization of non-culprit lesions?]. Ann Cardiol Angeiol (Paris) 2014; 63:262-4. [PMID: 24834992 DOI: 10.1016/j.ancard.2014.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 04/08/2014] [Indexed: 10/25/2022]
Abstract
Approximately 50% of patients admitted for ST-elevation myocardial infarction (STEMI) have multi-vessel disease. Current guidelines recommend revascularization of the culprit lesion only during the initial procedure except in cardiogenic shock. Benefits of revascularization of associated functional lesions are not debate. However, timing of the procedure is not clear. This article is a review over timing of secondary revascularization in STEMI patients with multi-vessels disease.
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Liu KL, Lee KT, Chang CH, Chen YC, Lin SM, Chu PH. Elevated plasma thrombomodulin and angiopoietin-2 predict the development of acute kidney injury in patients with acute myocardial infarction. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R100. [PMID: 24886544 PMCID: PMC4075148 DOI: 10.1186/cc13876] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 05/02/2014] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Acute kidney injury (AKI) following acute myocardial infarction (AMI) is associated with unfavorable prognosis. Endothelial activation and injury were found to play a critical role in the development of both AKI and AMI. This pilot study aimed to determine whether the plasma markers of endothelial injury and activation could serve as independent predictors for AKI in patients with AMI. METHODS This prospective study was conducted from March 2010 to July 2012 and enrolled consecutive 132 patients with AMI receiving percutaneous coronary intervention (PCI). Plasma levels of thrombomodulin (TM), von Willebrand factor (vWF), angiopoietin (Ang)-1, Ang-2, Tie-2, and vascular endothelial growth factor (VEGF) were measured on day 1 of AMI. AKI was defined as elevation of serum creatinine of more than 0.3 mg/dL within 48 hours. RESULTS In total, 13 out of 132 (9.8%) patients with AMI developed AKI within 48 hours. Compared with patients without AKI, patients with AKI had increased plasma levels of Ang-2 (6338.28 ± 5862.77 versus 2412.03 ± 1256.58 pg/mL, P = 0.033) and sTM (7.6 ± 2.26 versus 5.34 ± 2.0 ng/mL, P < 0.001), and lower estimated glomerular filtration rate (eGFR) (46.5 ± 20.2 versus 92.5 ± 25.5 mL/min/1.73 m2, P < 0.001). Furthermore, the areas under the receiver operating curves demonstrated that plasma thrombomodulin (TM) and Ang-2 levels on day 1 of AMI had modest discriminative powers for predicting AKI development following AMI (0.796, P <0.001; 0.833, P <0.001; respectively). CONCLUSIONS Endothelial activation, quantified by plasma levels of TM and Ang-2 may play an important role in development of AKI in patients with AMI.
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Impact of multivessel disease on infarct size among STEMI patients undergoing primary angioplasty. Atherosclerosis 2014; 234:244-8. [DOI: 10.1016/j.atherosclerosis.2014.02.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 02/20/2014] [Accepted: 02/28/2014] [Indexed: 11/20/2022]
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Singh V, Cohen MG. Therapy in ST-elevation myocardial infarction: reperfusion strategies, pharmacology and stent selection. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:302. [PMID: 24668011 DOI: 10.1007/s11936-014-0302-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OPINION STATEMENT The estimated annual incidence of new and recurrent myocardial infarction (MI) in the U.S. is 715,000 events. Primary percutaneous coronary intervention (PCI) is the reperfusion strategy of choice in most patients with acute ST-elevation myocardial infarction (STEMI). Recent advances in percutaneous techniques and devices, including manual aspiration catheters and newer generation drug eluting stents and pharmacologic therapies, such as novel antiplatelets and anticoagulants have led to significant improvements in the acute and long-term outcomes for these patients. Implementation of community-wide systems directed to shorten treatment times tied to closely monitored quality improvement processes have led to further advances in STEMI care. Recent data suggests that transradial access for primary PCI is associated with improved outcomes. This contemporary review discusses the strategies for reperfusion, pharmacological therapy and stent selection process involved in STEMI.
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Affiliation(s)
- Vikas Singh
- Cardiovascular Division, and the Elaine and Sydney Sussman Cardiac Catheterization Laboratory, University of Miami Hospital, Miller School of Medicine, 1400 N.W. 12th Avenue, Suite 1179, Miami, FL, 33136, USA
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Percutaneous coronary intervention in treatment of multivessel coronary artery disease in patients with non-ST-segment elevation acute coronary syndrome. Adv Cardiol 2014; 9:136-45. [PMID: 24570706 PMCID: PMC3915974 DOI: 10.5114/pwki.2013.35448] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 04/22/2013] [Accepted: 05/09/2013] [Indexed: 11/23/2022]
Abstract
Among patients with non-ST-elevated acute coronary syndromes (NSTE-ACS) the estimated percentage of single vessel coronary artery disease (SV-CAD) observed during coronarography is about 20-40%, while multivessel coronary artery disease (MV-CAD) is found in about 40-60%. Further treatment in patients with both SV CAD and MV CAD is usually culprit vessel percutaneous coronary intervention (CV-PCI). Nevertheless, in the group of patients with MV-CAD there is still a problematic decision whether the non-infarct related arteries (non-IRA) should be treated with PCI. According to the European Society of Cardiology (ESC) guidelines on myocardial revascularization this decision should be based on the overall clinical and angiographic status of the patient; simultaneously they suggest performing ad hoc CV-PCI. The decision of performing intervention in the rest of the narrowed coronary arteries should be made after consultation with the heart team or according to the protocols adopted in the specific clinic. Furthermore, there is a question of whether the procedure should be performed immediately after culprit vessel revascularization or it should be postponed until the patient is stabilized. Due to the lack of specific recommendations we decided to perform an analysis of existing studies which compared culprit versus multivessel revascularization in patients with MV-CAD and non-ST-elevated acute coronary syndromes.
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Naito R, Miyauchi K, Ogita M, Kasai T, Kawaguchi Y, Tsuboi S, Konishi H, Okazaki S, Kurata T, Daida H. Impact of admission glycemia and glycosylated hemoglobin A1c on long-term clinical outcomes of non-diabetic patients with acute coronary syndrome. J Cardiol 2014; 63:106-11. [DOI: 10.1016/j.jjcc.2013.07.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 07/09/2013] [Accepted: 07/31/2013] [Indexed: 01/08/2023]
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Hoebers LP, Vis MM, Claessen BE, van der Schaaf RJ, Kikkert WJ, Baan J, de Winter RJ, Piek JJ, Tijssen JG, Dangas GD, Henriques JP. The impact of multivessel disease with and without a co-existing chronic total occlusion on short- and long-term mortality in ST-elevation myocardial infarction patients with and without cardiogenic shock. Eur J Heart Fail 2014; 15:425-32. [DOI: 10.1093/eurjhf/hfs182] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | | | | | | | | | - Jan Baan
- Academic Medical Center Amsterdam; The Netherlands
| | | | - Jan J. Piek
- Academic Medical Center Amsterdam; The Netherlands
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Bainey KR, Mehta SR, Lai T, Welsh RC. Complete vs culprit-only revascularization for patients with multivessel disease undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: a systematic review and meta-analysis. Am Heart J 2014; 167:1-14.e2. [PMID: 24332136 DOI: 10.1016/j.ahj.2013.09.018] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 09/30/2013] [Indexed: 12/28/2022]
Abstract
BACKGROUND Patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease who undergo primary percutaneous coronary intervention (PCI) are most commonly treated with PCI to the culprit lesion only. Whether a strategy of complete revascularization in these patients is superior is unknown. We performed a meta-analysis comparing the benefits and risks of routine culprit-only PCI vs multivessel PCI in STEMI. METHODS MEDLINE, EMBASE, ISI Web of Science, and The Cochrane Register of Controlled Trials were searched from 1996 to January 2011. Relevant conference abstracts were searched from January 2002 to January 2011. Studies included STEMI with multivessel disease receiving primary PCI. The primary end point was long-term mortality. Data were combined using a fixed-effects model. RESULTS Of 507 citations, 26 studies (3 randomized, 23 nonrandomized; 46,324 patients, 7886 multivessel PCI and 38,438 culprit-only PCI) were included. There was no significant difference in hospital mortality with multivessel PCI vs culprit-only PCI (odds ratio [OR] 1.11, 95% CI 0.98-1.25, P = .10 [randomized OR 0.24, 95% CI 0.06-0.91, P = .04; nonrandomized OR 1.12, 95% CI 1.00-1.27, P = .06]). However, if multivessel PCI during index catheterization was performed, hospital mortality was increased (OR 1.35, 95% CI 1.19-1.54, P < .001). When multivessel PCI was performed as a staged procedure, hospital mortality was lower (OR 0.35, 95% CI 0.21-0.59; P < .001; P interaction < .001). Reduced long-term mortality (OR 0.74, 95% CI 0.65-0.85, P < .001[randomized OR 0.61, 95% CI 0.28-1.33, P = .22; nonrandomized OR 0.75, 95% CI 0.65-0.86, P < .001]) and repeat PCI (OR 0.65; 95% 0.46-0.90, P = .01[randomized OR 0.31, 95% CI 0.17-0.57, P < .001; nonrandomized OR 0.88, 95% CI 0.59-1.31, P = .54]) were observed with multivessel PCI. CONCLUSION Overall, staged multivessel PCI improved short- and long-term survival and reduced repeat PCI. Still, large randomized trials are required to confirm the benefits of staged multivessel PCI in STEMI.
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The great taboo of non-infarct-related artery revascularization during primary percutaneous coronary intervention. Am Heart J 2013; 166:611-3. [PMID: 24093838 DOI: 10.1016/j.ahj.2013.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 06/29/2013] [Indexed: 11/20/2022]
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Bagai A, Thavendiranathan P, Sharieff W, Al Lawati HA, Cheema AN. Non-infarct-related artery revascularization during primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: a systematic review and meta-analysis. Am Heart J 2013; 166:684-693.e1. [PMID: 24093848 DOI: 10.1016/j.ahj.2013.07.027] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 07/16/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND In patients with ST-elevation myocardial infarction (STEMI) and multivessel disease, guidelines recommend infarct-related artery (IRA) only intervention during primary percutaneous coronary intervention (PCI) except in patients with hemodynamic instability. To assess the available evidence, we performed a systematic review and meta-analysis comparing outcomes of non-IRA PCI as an adjunct to primary PCI (same sitting PCI [SS-PCI]) with IRA only PCI (IRA-PCI) in the setting of STEMI. METHODS AND RESULTS A comprehensive search identified 14 studies [11 cohort, 3 randomized controlled trials] comprising of 35,239 patients. For cohort studies, patients undergoing SS-PCI had higher rate of anterior infarction (48% vs. 45%, P = .04) and cardiogenic shock (11% vs. 9%, P = .0001) at baseline compared with IRA-PCI. The primary composite end point of death, myocardial infarction and revascularization was higher in the SS-PCI group in the short term (OR, 1.63; CI, 1.12-2.37) and long term (OR, 1.60; CI, 1.18-2.16). However, after excluding patients with shock, there was no difference in primary endpoint for the short (OR, 1.33; CI, 0.67-2.63) and long term (OR, 1.39; CI, 0.80-2.42) follow-up. In analyses limited to randomized controlled trials, primary end point was similar during short term (OR, 0.79; CI, 0.19-3.28) and significantly lower for SS-PCI group in the long term (OR, 0.55; CI, 0.34-0.91). CONCLUSIONS There is paucity of randomized data to guide management of STEMI patients with multivessel disease. SS-PCI group in cohort studies has higher baseline risk compared to IRA-PCI. The primary end point is higher for SS-PCI in observational cohort studies but this difference did not persist after exclusion of shock patients and for analysis limited to randomized controlled trials. These findings underscore the need of a large randomized controlled trial to guide therapy for a commonly encountered clinical situation.
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Loh JP, Kitabata H, Torguson R, Satler LF, Kent KM, Suddath WO, Pichard AD, Lindsay J, Waksman R. Safety and feasibility of performing staged non-culprit vessel percutaneous coronary intervention within the index hospitalization in patients with ST-segment elevation myocardial infarction and multivessel disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2013; 14:258-63. [PMID: 24034862 DOI: 10.1016/j.carrev.2013.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 05/20/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To determine whether staged percutaneous coronary intervention (PCI) within the same hospitalization as primary PCI is safe. BACKGROUND In ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease undergoing primary PCI, staged non-culprit vessel PCI at a separate session is recommended. METHODS We conducted a retrospective analysis of 282 consecutive STEMI patients with multivessel disease who underwent primary PCI followed by staged PCI of the non-culprit vessel. Patients were categorized into staged PCI in the same hospitalization (n=184) and staged PCI at a separate hospitalization within 8 weeks of primary PCI (n=98). RESULTS Baseline characteristics, presentation of STEMI, and procedural characteristics were similar in both groups. Contrast amount was higher in the separate hospitalization group for both index (175 vs. 153 ml, p=0.011) and staged (144 vs. 120 ml, p=0.004) procedures. More staged left main PCI was performed in the separate hospitalization group (3.9 vs. 0.3%, p=0.008). Angiographic success of staged PCI was similar in both groups, with similar rates of vascular complications and major bleeding. Following staged PCI, in-hospital major adverse cardiac events (3.3 vs. 1.0%, p=0.43) and mortality (2.7 vs. 0%, p=0.17) were similar in both groups. CONCLUSIONS Our study supports the safety and feasibility of staged PCI within the same hospitalization as primary PCI, achieving similar procedural success and in-hospital outcomes as staged PCI at a separate hospitalization. Higher contrast amount used during primary PCI and presence of left main lesion in non-culprit vessels may influence the decision to stage the PCI at a separate hospitalization.
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Affiliation(s)
- Joshua P Loh
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
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Impact of chronic total occlusion artery on 12-month mortality in patients with non-ST-segment elevation myocardial infarction treated by percutaneous coronary intervention (From the PL-ACS Registry). Int J Cardiol 2013; 168:250-4. [DOI: 10.1016/j.ijcard.2012.09.086] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 06/11/2012] [Accepted: 09/15/2012] [Indexed: 11/24/2022]
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Abe D, Sato A, Hoshi T, Takeyasu N, Misaki M, Hayashi M, Aonuma K. Initial culprit-only versus initial multivessel percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction: results from the Ibaraki Cardiovascular Assessment Study registry. Heart Vessels 2013; 29:171-7. [DOI: 10.1007/s00380-013-0342-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 03/08/2013] [Indexed: 11/30/2022]
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O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX, Anderson JL, Jacobs AK, Halperin JL, Albert NM, Brindis RG, Creager MA, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Kushner FG, Ohman EM, Stevenson WG, Yancy CW. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2012; 127:e362-425. [PMID: 23247304 DOI: 10.1161/cir.0b013e3182742cf6] [Citation(s) in RCA: 1059] [Impact Index Per Article: 88.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2012; 61:e78-e140. [PMID: 23256914 DOI: 10.1016/j.jacc.2012.11.019] [Citation(s) in RCA: 2176] [Impact Index Per Article: 181.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Lu C, Huang H, Li J, Zhao J, Zhang Q, Zeng Z, Chen Y. Complete versus culprit-only revascularization during primary percutaneous coronary intervention in ST-elevation myocardial infarction patients with multivessel disease: a meta-analysis. Kaohsiung J Med Sci 2012; 29:140-9. [PMID: 23465417 DOI: 10.1016/j.kjms.2012.08.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Accepted: 12/19/2011] [Indexed: 02/05/2023] Open
Abstract
Complete versus culprit-only revascularization in acute ST-elevation myocardial infarction (STEMI) patients with multivessel disease is controversial. Current guidelines recommend treatment of the culprit artery alone during the primary procedure. However, with improvements in stent technique and with the use of new antiplatelet drugs (GP IIb/IIIa inhibitors), complete revascularization (CR) at an early stage is attracting increasing attention. We conducted an English language search on Medline (PubMed database), Embase, and the Cochrane databases between January 1966 and January 2011, as well as a search on the China National Knowledge Internet (1979-January 2011), and the Chinese Biomedical Literature Database (1978-January 2011). Randomized controlled trials (RCTs) or non-RCTs that compared the two strategies in patients with STEMI and multivessel disease (MVD) during primary percutaneous coronary intervention (PCI) were included. Thirteen articles were selected, 8240 patients in the CR group and 51,998 in the culprit-only revascularization group. CR was associated with an increased short-term mortality [odds ratio (OR) = 1.39, 95% confidence interval (CI) = (1.26, 1.53)], a long-term mortality [OR = 1.35, 95% CI = (1.09, 1.67)], and an increased risk of renal failure [OR (95% CI) = 1.24 (1.11, 1.38)] in patients with STEMI and MVD at the primary procedure. In addition, CR did not reduce the rate of short-term major adverse cardiac events [OR (95% CI) = 1.52 (0.88, 2.61)] and remyocardial infarction [OR = 0.57, 95% CI = (0.25, 1.29)]. However, CR was associated with a marked reduction in the rate of revascularization [OR = 0.45, 95% CI = (0.27, 0.74)]. This analysis of current available data demonstrates that CR during primary PCI can put those patients with STEMI and MVD at risk. To clarify this issue, large RCTs are needed.
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Affiliation(s)
- Cong Lu
- Division of Cardiology, West China Hospital, Sichuan University, Chengdu, China
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Hong MK. Recent Advances in the Treatment of ST-Segment Elevation Myocardial Infarction. SCIENTIFICA 2012; 2012:683683. [PMID: 24278728 PMCID: PMC3820598 DOI: 10.6064/2012/683683] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 09/12/2012] [Indexed: 06/02/2023]
Abstract
ST-segment elevation myocardial infarction (STEMI) represents the most urgent condition for patients with coronary artery disease. Prompt diagnosis and therapy, mainly with primary angioplasty using stents, are important in improving not only acute survival but also long-term prognosis. Recent advances in angioplasty devices, including manual aspiration catheters and drug-eluting stents, and pharmacologic therapy, such as potent antiplatelet and anticoagulant agents, have significantly enhanced the acute outcome for these patients. Continuing efforts to educate the public and to decrease the door-to-balloon time are essential to further improve the outcome for these high-risk patients. Future research to normalize the left ventricular function by autologous stem cell therapy may also contribute to the quality of life and longevity of the patients surviving STEMI.
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Affiliation(s)
- Mun K. Hong
- Cardiac Catheterization Laboratory and Interventional Cardiology, St. Luke's-Roosevelt Hospital Center, 1111 Amsterdam Avenue, New York, NY 10025, USA
- Columbia University College of Physicians and Surgeons, 630 W. 168th St., New York, NY 10032, USA
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Jensen L, Thayssen P, Farkas D, Hougaard M, Terkelsen C, Tilsted HH, Maeng M, Junker A, Lassen JF, Horváth-Puhó E, Sørensen HT, Thuesen L. Culprit only or multivessel percutaneous coronary interventions in patients with ST-segment elevation myocardial infarction and multivessel disease. EUROINTERVENTION 2012; 8:456-64. [DOI: 10.4244/eijv8i4a72] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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75
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Multivessel Versus Culprit-Only Revascularization: One Time Versus Staged Procedures for the ACS Population. Curr Cardiol Rep 2012; 14:528-36. [DOI: 10.1007/s11886-012-0272-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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76
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The role of cardiac magnetic resonance imaging following acute myocardial infarction. Eur Radiol 2012; 22:1757-68. [PMID: 22447378 DOI: 10.1007/s00330-012-2420-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Revised: 01/08/2012] [Accepted: 01/25/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Advances in the management of myocardial infarction have resulted in substantial reductions in morbidity and mortality. METHODS However, after acute treatment a number of diagnostic and prognostic questions often remain to be answered, whereby cardiac imaging plays an essential role. RESULTS For example, some patients will sustain early mechanical complications after infarction, while others may develop significant ventricular dysfunction. Furthermore, many individuals harbour a significant burden of residual coronary disease for which clarification of functional ischaemic status and/or viability of the suspected myocardial territory is required. CONCLUSION Cardiac magnetic resonance (CMR) imaging is well positioned to fulfil these requirements given its unparalleled capability in evaluating cardiac function, stress ischaemia testing and myocardial tissue characterisation. This review will focus on the utility of CMR in resolving diagnostic uncertainty, evaluating early complications following myocardial infarction, assessing inducible ischaemia, myocardial viability, ventricular remodelling and the emerging role of CMR-derived measures as endpoints in clinical trials. KEY POINTS Cardiac magnetic resonance (CMR) imaging identifies early complications after myocardial infarction. • Adenosine stress CMR can reliably assess co-existing disease in non-culprit arteries. • Assessment of infarct size and microvascular obstruction a robust prognostic indicator. • Assessment of myocardial viability is important to guide revascularisation decision-making.
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Lopez-Palop R, Carrillo P, Torres F, Lozano I, Frutos A, Avanzas P, Cordero A, Rondán J. Resultados del empleo de la reserva fraccional de flujo en la valoración de lesiones no causales en el síndrome coronario agudo. Rev Esp Cardiol 2012; 65:164-70. [DOI: 10.1016/j.recesp.2011.09.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2011] [Accepted: 09/18/2011] [Indexed: 01/19/2023]
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Sadowski M, Gasior M, Gierlotka M, Janion M, Poloński L. Gender-related differences in mortality after ST-segment elevation myocardial infarction: a large multicentre national registry. EUROINTERVENTION 2011; 6:1068-72. [PMID: 21518678 DOI: 10.4244/eijv6i9a186] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Clinical outcomes in the treatment of acute ST-segment elevation myocardial infarction (STEMI) differ between men and women. The aim of the study was to compare results of STEMI management in a large multicentre national registry. METHODS AND RESULTS A total of 456 hospitals (including 58 interventional centres) participated in the registry during one year. The study group consisted of 8,989 (34.5%) females and 17,046 (65.5%) males. Women were older (69.7 ± 11 vs. 62 ± 12 years; p<0.0001) and had more risk factors. Percutaneous coronary intervention was performed significantly less in women (47.8% vs. 57.4%; p<0.0001). There was a longer time delay in women at each stage of treatment. The incidence of in-hospital complications was higher in women. In-hospital (11.9% vs. 6.9%; p<0.0001) and 12-months (22% vs. 14.1%; p<0.0001) mortality was significantly higher in women. In multivariate analysis pulmonary oedema, cardiogenic shock, cardiac arrest, age, diabetes and anterior infarction significantly increased both in-hospital and long-term mortality. The in-hospital mortality was higher in the female group. CONCLUSIONS Despite poor clinical characteristics, less than satisfactory management and a worse prognosis of STEMI in women, being a women itself is not a risk factor for increased long-term mortality, however, other well known risk factors affecting the prognosis relate frequently to the female gender.
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Lee HJ, Song YB, Hahn JY, Kim SM, Yang JH, Choi JH, Choi SH, Choi JH, Lee SH, Gwon HC. Multivessel vs single-vessel revascularization in patients with non-ST-segment elevation acute coronary syndrome and multivessel disease in the drug-eluting stent era. Clin Cardiol 2011; 34:160-5. [PMID: 21400543 DOI: 10.1002/clc.20858] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND We sought to compare long-term outcomes for multivessel revascularization (MVR) vs single-vessel revascularization (SVR) with drug-eluting stents (DES) in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and multivessel coronary artery disease (MVD). HYPOTHESIS In DES era, MVR would improve long-term clinical outcomes in patients with NSTE-ACS. METHODS We studied 179 patients undergoing MVR and 187 patients undergoing SVR for NSTE-ACS and MVD. Major adverse cardiac events (MACE) were defined as death, myocardial infarction, or any revascularization. RESULTS During follow-up (median 36 months), MACE occurred in 96 patients (26.2%); 35 (19.6%) in the MVR group and 61 (32.6%) in the SVR group (P=0.003). In multivariate analysis, MVR was associated with a lower incidence of MACE (hazard ratio [HR]: 0.50, 95% confidence interval [CI]: 0.30-0.85) and revascularization (HR: 0.43, 95% CI: 0.24-0.78), but not of death (HR: 0.69, 95% CI: 0.25-1.93) and myocardial infarction (HR: 0.39, 95% CI: 0.11-1.47). The incidence of periprocedural renal dysfunction was not significantly different between patients undergoing MVR vs SVR (3.4% vs 1.6%, P=0.33). Definite or probable stent thrombosis occurred at a similar rate (2.2% in the MVR group and 2.7% in the SVR group, P=0.99). CONCLUSIONS In patients with NSTE-ACS and MVD, MVR using drug-eluting stents may reduce MACE. Our findings should be confirmed by a prospective, randomized trial.
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Affiliation(s)
- Hyun Jong Lee
- Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Bangalore S, Kumar S, Poddar KL, Ramasamy S, Rha SW, Faxon DP. Meta-analysis of multivessel coronary artery revascularization versus culprit-only revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease. Am J Cardiol 2011; 107:1300-10. [PMID: 21349487 DOI: 10.1016/j.amjcard.2010.12.039] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Revised: 12/31/2010] [Accepted: 12/31/2010] [Indexed: 12/01/2022]
Abstract
American College of Cardiology/American Heart Association guidelines for management of patients with ST-segment elevation myocardial infarction (STEMI) recommend culprit artery-only revascularization (CULPRIT) based on safety concerns during noninfarct-related artery intervention. However, the data to support this safety concern are scant. Searches were performed in PubMed/EMBASE/CENTRAL for studies evaluating multivessel revascularization versus CULPRIT in patients with STEMI and multivessel disease (MVD). A multivessel revascularization strategy had to be performed at the time of CULPRIT or during the same hospitalization. Early (≤30-day) and long-term outcomes were evaluated. Among 19 studies (23 arms) that evaluated 61,764 subjects with STEMI and MVD, multivessel revascularization was performed in a minority of patients (16%). For early outcomes, there was no significant difference for outcomes of mortality, MI, stroke, and target vessel revascularization, with a 44% decrease in risk of repeat percutaneous coronary intervention and major adverse cardiovascular events (odds ratio 0.68, 95% confidence interval 0.57 to 0.81) with multivessel revascularization compared to CULPRIT. Similarly, for long-term outcomes (follow-up 2.0 ± 1.1 years), there was no difference for outcomes of MI, target vessel revascularization, and stent thrombosis, with 33%, 43%, and 53% decreases in risk of mortality, repeat percutaneous coronary intervention, coronary artery bypass grafting, respectively, and major adverse cardiovascular events (odds ratio 0.60, 95% confidence interval 0.50 to 0.72) with multivessel revascularization compared to CULPRIT. In conclusion, in patients with STEMI and MVD, multivessel revascularization appears to be safe compared to culprit artery-only revascularization. These findings support the need for a large-scale randomized trial to evaluate revascularization strategies in patients with STEMI and MVD.
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Affiliation(s)
- Sripal Bangalore
- Department of Medicine, Division of Cardiology, New York University School of Medicine, New York, New York, USA.
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Barringhaus KG, Park KL, McManus DD, Steg PG, Montalescot G, Van de Werf F, López-Sendón J, FitzGerald G, Gore JM. Outcomes from patients with multi-vessel disease following primary PCI. Catheter Cardiovasc Interv 2011; 77:617-22. [DOI: 10.1002/ccd.22784] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Maamoun W, Elkhaeat N, Elarasy R. Safety and feasibility of complete simultaneous revascularization during primary PCI in patients with STEMI and multi-vessel disease. Egypt Heart J 2011. [DOI: 10.1016/j.ehj.2011.08.030] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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83
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Coronary Revascularization Strategy for ST Elevation Myocardial Infarction with Multivessel Disease: Experience and Results at 1-Year Follow-Up. Am J Ther 2011; 18:92-100. [DOI: 10.1097/mjt.0b013e3181b809ee] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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84
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Sethi A, Bahekar A, Bhuriya R, Singh S, Ahmed A, Khosla S. Complete versus culprit only revascularization in acute ST elevation myocardial infarction: A meta-analysis. Catheter Cardiovasc Interv 2011; 77:163-70. [DOI: 10.1002/ccd.22647] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Widimsky P, Holmes DR. How to treat patients with ST-elevation acute myocardial infarction and multi-vessel disease? Eur Heart J 2011; 32:396-403. [PMID: 21118854 PMCID: PMC3038335 DOI: 10.1093/eurheartj/ehq410] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2010] [Revised: 09/18/2010] [Accepted: 10/05/2010] [Indexed: 01/05/2023] Open
Abstract
Over 50% of ST-segment elevation myocardial infarction (STEMI) patients suffer multi-vessel coronary artery disease, which is known to be associated with worse prognosis. Treatment strategies used in clinical practice vary from acute multi-vessel percutaneous coronary intervention (PCI), through staged PCI procedures to a conservative approach with primary PCI of only the infarct-related artery (IRA) and subsequent medical therapy unless recurrent ischaemia occurs. Each approach has advantages and disadvantages. This review paper summarizes the international experience and authors' opinion on this clinically important question. Multi-vessel disease in STEMI is not a single entity and thus the treatment approach should be individualized. However, the following general rules can be proposed till future large randomized trials prove otherwise: (i) Single-vessel acute PCI should be the default strategy (to treat only the IRA during the acute phase of STEMI). (ii) Acute multi-vessel PCI can be justified only in exceptional patients with multiple critical (>90%) and potentially unstable lesions. (iii) Significant lesions of the non-infarct arteries should be treated either medically or by staged revascularization procedures-both options are currently acceptable.
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Affiliation(s)
- Petr Widimsky
- Cardiocenter, Third Faculty of Medicine, Charles University Prague, Hospital Kralovske Vinohrady, Prague 10, Czech Republic.
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Navarese EP, De Servi S, Buffon A, Suryapranata H, De Luca G. Clinical impact of simultaneous complete revascularization vs. culprit only primary angioplasty in patients with st-elevation myocardial infarction and multivessel disease: a meta-analysis. J Thromb Thrombolysis 2010; 31:217-25. [DOI: 10.1007/s11239-010-0510-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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87
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Dziewierz A, Siudak Z, Rakowski T, Zasada W, Dubiel JS, Dudek D. Impact of multivessel coronary artery disease and noninfarct-related artery revascularization on outcome of patients with ST-elevation myocardial infarction transferred for primary percutaneous coronary intervention (from the EUROTRANSFER Registry). Am J Cardiol 2010; 106:342-7. [PMID: 20643243 DOI: 10.1016/j.amjcard.2010.03.029] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Revised: 03/22/2010] [Accepted: 03/22/2010] [Indexed: 11/28/2022]
Abstract
The aim of the study was to assess the impact of multivessel coronary artery disease (MVD) and noninfarct-related artery (non-IRA) revascularization during index percutaneous coronary intervention (PCI) on outcomes of patients with ST-segment elevation myocardial infarction (STEMI). Data on 1,598 of 1,650 patients with complete angiographic data, with >or=1 significantly stenosed epicardial coronary artery, and without previous coronary artery bypass grafting were retrieved from the EUROTRANSFER Registry database. Patients with 1-, 2-, and 3-vessel disease made up 48.5%, 32.0%, and 19.5% of the registry population, respectively. Patients with MVD were less likely to achieve final Thrombolysis In Myocardial Infarction grade 3 flow (1- vs 2- vs 3-vessel disease, 93.6% vs 89.3% vs 87.9%, respectively, p = 0.003) and ST-segment resolution >50% within 60 minutes after PCI (1- vs 2- vs 3-vessel disease, 80.9% vs 77.5% vs 69.3%, respectively, p <0.001). They were also at higher risk of death during 1-year follow-up (1- vs 2- vs 3-vessel disease, 4.9% vs 7.4% vs 13.5%, respectively, p <0.001), and MVD was identified as an independent predictor of 1-year death. In 70 patients (9%) non-IRA PCI was performed during index PCI. These patients were at higher risk of 30-day and 1-year death compared to patients without non-IRA PCI, but this difference in mortality was no longer significant after adjustment for covariates. In conclusion, patients with MVD have decreased epicardial and myocardial reperfusion success and had worse prognosis after primary PCI for STEMI compared to patients with 1-vessel disease. In this large multicenter registry, non-IRA PCI during the index procedure was performed in 9% of patients with MVD and it was associated with increased 1-year mortality.
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88
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Toma M, Buller CE, Westerhout CM, Fu Y, O'Neill WW, Holmes DR, Hamm CW, Granger CB, Armstrong PW. Non-culprit coronary artery percutaneous coronary intervention during acute ST-segment elevation myocardial infarction: insights from the APEX-AMI trial. Eur Heart J 2010; 31:1701-7. [DOI: 10.1093/eurheartj/ehq129] [Citation(s) in RCA: 174] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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89
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Bangalore S, Faxon DP. Coronary Intervention in Patients With Acute Coronary Syndrome: Does Every Culprit Lesion Require Revascularization? Curr Cardiol Rep 2010; 12:330-7. [DOI: 10.1007/s11886-010-0115-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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90
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Chen HC, Tsai TH, Fang HY, Sun CK, Lin YC, Leu S, Chung SY, Chai HT, Yang CH, Hsien YK, Wu CJ, Yip HK. Benefit of Revascularization in Non-Infarct-Related Artery in Multivessel Disease Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. Int Heart J 2010; 51:319-24. [DOI: 10.1536/ihj.51.319] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Huang-Chung Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Tzu-Hsien Tsai
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Hsiu-Yu Fang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Cheuk-Kwan Sun
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Yu-Chun Lin
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Steve Leu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Sheng-Ying Chung
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Han-Tan Chai
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Cheng-Hsu Yang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Yuan-Kai Hsien
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Chiung-Jen Wu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Hon-Kan Yip
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
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91
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Culprit only versus multivessel coronary revascularization in patients presenting with acute ST elevation myocardial infarction: Unending debate. Int J Cardiol 2009; 137:65-6. [DOI: 10.1016/j.ijcard.2008.05.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Accepted: 05/03/2008] [Indexed: 11/22/2022]
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92
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Comparative effects of percutaneous coronary intervention for infarct-related artery only or for both infarct- and non-infarct-related arteries in patients with ST-elevation myocardial infarction and multi-vessel disease. Chin Med J (Engl) 2008. [DOI: 10.1097/00029330-200812010-00004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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93
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Rigattieri S, Biondi-Zoccai G, Silvestri P, Di Russo C, Musto C, Ferraiuolo G, Loschiavo P. Management of Multivessel Coronary Disease after ST Elevation Myocardial Infarction Treated by Primary Angioplasty. J Interv Cardiol 2008; 21:1-7. [PMID: 18086133 DOI: 10.1111/j.1540-8183.2007.00317.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Stefano Rigattieri
- Interventional Cardiology Unit, Cardiology Department, "Sandro Pertini" Hospital, Rome, Italy.
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94
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Conde-Vela C, Moreno R, Hernández R, Pérez-Vizcayno MJ, Alfonso F, Escaned J, Sabaté M, Bañuelos C, Macaya C. Cardiogenic shock at admission in patients with multivessel disease and acute myocardial infarction treated with percutaneous coronary intervention: Related factors. Int J Cardiol 2007; 123:29-33. [PMID: 17303267 DOI: 10.1016/j.ijcard.2006.11.102] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2006] [Accepted: 11/09/2006] [Indexed: 11/27/2022]
Abstract
BACKGROUND Among patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI), those with multivessel disease have worse prognosis, mainly due to a higher frequency of cardiogenic shock (CS) at admission. The aim of this study was to identify clinical and angiographic characteristics of patients with STEMI, multivessel disease and CS at admission referred to primary PCI. METHODS We studied 630 patients with STEMI treated with primary PCI within 12 h after symptoms onset. Multivessel disease was defined as the presence of >or=50% stenosis in >or=2 major epicardial arteries. Multivessel disease was documented in 276 patients (44%), these patients comprising the study population. Clinical, angiographic and procedural variables were compared between those with and without CS. A logistic regression analysis was performed to identify the independent predictors of CS among patients with multivessel disease. RESULTS Among patients with multivessel disease, 45 (16%) had CS at admission. The independent predictors of CS in patients with multivessel disease were: STEMI anterior [OR 2.05; 95% CI 1.0 to 4.1; p=0.044], female gender [odds ratio (OR) 2.49; 95% confidence intervals (CI) 1.1 to 5.3; p=0.021], proximal culprit lesion [OR 3.8; 95% CI 1.7 to 8.5; p<0.001], and chronic occlusion of other coronary arteries [OR 4.48; 95% CI 2.1 to 9.1; p<0.001]. CONCLUSIONS Among patients with STEMI and multivessel disease, CS is especially frequent in STEMI anterior, female gender, proximal culprit lesion, and chronic occlusion of other vessels.
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Affiliation(s)
- César Conde-Vela
- Division of Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
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95
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Xu F, Chen YG, Li JF, Li GS, Ji QS, Lv RJ, Li RJ, Sun Y, Zhang W, Li L, Zhang Y. Multivessel Percutaneous Coronary Intervention in Chinese Patients with Acute Myocardial Infarction and Simple Nonculprit Arteries. Am J Med Sci 2007; 333:376-80. [PMID: 17570991 DOI: 10.1097/maj.0b013e318065acfb] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Multivessel percutaneous coronary intervention (PCI) for patients during acute myocardial infarction (AMI) is currently controversial. In this study, we investigated the significance of multivessel PCI in Chinese patients with ST-segment elevation AMI and relatively simple lesions in nonculprit arteries. METHODS We reviewed all consecutive primary PCI of ST-segment elevation AMI in our hospital between 2002 and 2005. The patients with multivessel disease and ACC/AHA type A/B1 lesions in nonculprit arteries who underwent multivessel PCI were identified (n = 105, multivessel PCI group), and 120 patients with single-vessel disease and treatment with primary PCI were enrolled as control subjects (single-vessel PCI group). The primary end points were the occurrences of 6-month major adverse cardiac events (cardiogenic death, nonfatal reinfarction, and target vessel revascularization). The secondary end points included procedure time, angiographic success rate, TIMI grade, reperfusion arrhythmia, ST-segment resolution, and left ventricular ejection fraction. RESULTS All patients with multivessel PCI tolerated the operations well and had similar TIMI 3 and angiographic success rates but longer procedure times than those patients with single-vessel PCI. There were no significant differences in reperfusion arrhythmia, ST-segment resolution, left ventricular ejection fraction, or 6-month MACEs between both groups. CONCLUSIONS This study suggests that multivessel PCI is effective and safe for Chinese patients with ST-segment elevation AMI and simple lesions in nonculprit arteries.
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Affiliation(s)
- Feng Xu
- Department of Emergency and Center of Chest Pain, Qilu Hospital of Shandong University, Jinan, China
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96
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Koszegi Z, Szerafin T, Edes I. “Late–late” retrograde collateral filling from occluded donor coronary artery. Int J Cardiol 2006; 112:e42-4. [PMID: 16839623 DOI: 10.1016/j.ijcard.2006.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2005] [Accepted: 02/24/2006] [Indexed: 10/24/2022]
Abstract
We present a case where the chronically occluded right coronary artery fed retrograde the acutely occluded left anterior descending artery. The "late-late" filling of the target vessel served as a good guide for the recanalisation procedure.
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97
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Harjai KJ, Mehta RH, Stone GW, Boura JA, Grines L, Brodie BR, Cox DA, O'Neill WW, Grines CL. Does Proximal Location of Culprit Lesion Confer Worse Prognosis in Patients Undergoing Primary Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction? J Interv Cardiol 2006; 19:285-94. [PMID: 16881971 DOI: 10.1111/j.1540-8183.2006.00146.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
ST segment elevation myocardial infarction (STEMI) from proximally located culprit lesion is associated with greater myocardium at jeopardy. In STEMI patients treated with thrombolytics, proximal culprit lesions are known to have worse prognosis. This relation has not been studied in patients undergoing primary percutaneous coronary intervention (PCI). In 3,535 STEMI patients with native coronary artery occlusion pooled from the primary angioplasty in myocardial infarction database, we compared in-hospital and 1-year outcomes between those with proximal (n = 1,606) versus non-proximal (n = 1,929) culprit lesions. Patients with proximal culprits were more likely to die and suffer major adverse cardiovascular events (MACE) during the index hospital stay (3.8% vs 2.2%, P = 0.006; 8.2% vs 5.8%, P = 0.0066, respectively) as well as during 1-year follow-up (6.9% vs 4.5%, P = 0.0013; 22% vs 17%, P = 0.003, respectively) compared to those with non-proximal culprits. After adjustment for baseline differences, proximal culprit was independently predictive of in-hospital death (adjusted odds ratio% 1.58, 95% confidence intervals, CI 1.05-2.40) and MACE (OR 1.41, CI 1.06-1.86), but not 1-year death or MACE. In addition, proximal culprit was independently associated with higher incidence of ventricular arrhythmias and sustained hypotension during the index hospitalization. The univariate impact of proximal culprit lesion on in-hospital death and MACE was comparable to other adverse angiographic characteristics, such as multivessel disease and poor initial thrombolysis in myocardial infarction flow, and greater than that of anterior wall STEMI. In conclusion, proximal location of the culprit lesion is a strong independent predictor of worse in-hospital outcomes in patients with STEMI undergoing primary PCI.
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98
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Corpus RA, House JA, Marso SP, Grantham JA, Huber KC, Laster SB, Johnson WL, Daniels WC, Barth CW, Giorgi LV, Rutherford BD. Multivessel percutaneous coronary intervention in patients with multivessel disease and acute myocardial infarction. Am Heart J 2004; 148:493-500. [PMID: 15389238 DOI: 10.1016/j.ahj.2004.03.051] [Citation(s) in RCA: 143] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND The optimal percutaneous interventional strategy for dealing with significant non-culprit lesions in patients with multivessel disease (MVD) with acute myocardial infarction (AMI) at presentation remains controversial. METHODS A total of 820 patients treated with primary angioplasty for AMI between 1998 and 2002 were classified in groups of patients with single vessel disease (SVD) or MVD (> or =70% stenosis of > or =2 coronary arteries). Patients with MVD were subdivided in 3 groups on the basis of the revascularization strategy: 1) patients undergoing percutaneous coronary intervention (PCI) of the infarct-related artery (IRA) only; 2) patients undergoing PCI of both the IRA and non-IRA(s) during the initial procedure; and 3) patients undergoing PCI of the IRA followed by staged, in-hospital PCI of the non-IRA(s). Procedural, 30-day, and 1-year outcomes are reported. RESULTS At 1 year, compared with patients with SVD, patients with MVD had a higher incidence of re-infarction (5.9% vs 1.6%, P =.003), revascularization (18% vs 9.6%, P <.001), mortality (12% vs 3.2%, P <.001), and major adverse cardiac events (MACEs; 31% vs 13%, P <.001). In patients with MVD, compared with PCI restricted to the IRA only, multivessel PCI was associated with higher rates of re-infarction (13.0% vs 2.8%, P <.001), revascularization (25% vs 15%, P =.007), and MACEs (40% vs 28%, P =.006). Multivessel PCI was an independent predictor of MACEs at 1 year (odds ratio = 1.67, P =.01). CONCLUSIONS These data suggest that in patients with MVD, PCI should be directed at the IRA only, with decisions about PCI of non-culprit lesions guided by objective evidence of residual ischemia at late follow-up. Further studies are needed to confirm these findings.
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Affiliation(s)
- Roberto A Corpus
- Section of Cardiology, Biostatistics, and Outcomes Research, Mid America Heart Institute, St. Luke's Hospital, Kansas City, Mo 64111, USA
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99
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Hanratty CG, Koyama Y, Rasmussen HH, Nelson GIC, Hansen PS, Ward MR. Exaggeration of nonculprit stenosis severity during acute myocardial infarction: implications for immediate multivessel revascularization. J Am Coll Cardiol 2002; 40:911-6. [PMID: 12225715 DOI: 10.1016/s0735-1097(02)02049-1] [Citation(s) in RCA: 144] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES This study was designed to assess the prevalence and clinical significance of exaggerated nonculprit lesion stenosis in the setting of acute (<12 h) myocardial infarction (AMI). BACKGROUND Although microvascular spasm may reduce nonculprit artery flow during AMI, it is unknown whether increased tone may exaggerate nonculprit lesion severity. METHODS In patients with additional angiography within nine months of AMI, and significant nonculprit lesions imaged in matching views, stenosis severity was compared between studies in a random blinded fashion using validated quantitative coronary angiography software. Baseline demographics, medications, hemodynamics at each study, and clinical status at follow-up (infarct/unstable angina/stable angina) were used to determine the independent influence of the infarct presentation on stenosis exaggeration. RESULTS From 548 patients with AMI (1/99 to 6/01, 321 with multivessel disease), 112 had additional angiography; of these 48 had 59 lesions suitable for analysis. Between infarct and noninfarct angiograms there was a significant change in minimal lumen diameter (1.53 +/- 0.51 mm vs. 1.78 +/- 0.65 mm, p < 0.001) and percentage stenosis (49.3 +/- 14.5% vs. 40.4 +/- 16.6%, p < 0.0001) of the nonculprit lesion without significant change in reference segment diameter, which was not predicted by changes in medication or hemodynamics. Twenty-one percent of patients had lesions >50% at AMI that were <50% at non-AMI angiography. Infarct versus noninfarct setting was the only significant independent predictor of change in nonculprit stenosis. CONCLUSIONS Significant exaggeration of nonculprit lesion stenosis severity occurs at infarct angiography, which may affect revascularization decision making in an appreciable number of patients.
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Affiliation(s)
- Colm G Hanratty
- Department of Cardiology, Royal North Shore Hospital, Sydney, Australia
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100
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Moreno R, García E, Soriano J, Abeytua M, Martínez-Sellés M, Acosta J, Elízaga J, Botas J, Rubio R, López de Sá E, López-Sendón JL, Delcán JL. [Coronary angioplasty in the acute myocardial infarction: in which patients is it less likely to obtain an adequate coronary reperfusion?]. Rev Esp Cardiol 2000; 53:1169-76. [PMID: 10978231 DOI: 10.1016/s0300-8932(00)75221-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION In patients with acute myocardial infarction treated with primary angioplasty, the inability to achieve successful coronary reperfusion is associated with higher mortality. The objective of the study was to identify which characteristics may predict a lower angiographic success rate in patients with acute myocardial infarction treated with coronary angioplasty. PATIENTS AND METHODS The study population is constituted by the 790 patients with acute myocardial infarction that were treated with angioplasty within the 12 hours after the onset of symptoms from 1991 to 1999 at our institution. A successful angiographic result was considered in presence of a residual stenosis < 50% and a TIMI flow 2 or 3 after the procedure. RESULTS A successful angiographic result and a final TIMI 3 flow were achieved in 736 (93.2%) and 652 (82.5%) patients, respectively. In-hospital mortality was higher in patients with angiographic failure than in those with angiographic successful result (48 vs. 10%; p < 0.01). Age under 65 (91 vs. 95%; p = 0.02), non smoking (90 vs. 96%; p < 0,01), previous infarction (87 vs. 94%; p < 0.01), angioplasty after failed thrombolysis (83 vs. 94%; p = 0. 02), cardiogenic shock (80 vs. 95%; p < 0.01), undetermined location (67 vs. 93%; p < 0.01), non-inferior location (92 vs. 96%; p = 0.04), left bundle branch block (64 vs. 94%; p < 0.01), multivessel disease (91 vs. 95%; p = 0.02), left ventricular ejection fraction < 0.40 (89 vs. 97%; p < 0.01), no utilization of coronary stenting (90 vs. 96%; p < 0.01), and use of intraaortic balloon counterpulsation pump (82 vs. 95%; p < 0.01) were associated with a lower angiographic success rate. In the multivariable analysis, the following were independent predictors for angiographic failure: left bundle branch block (odds ratio [OR], 12.95; CI 95%, 3.00-53.90), cardiogenic shock (OR, 4.20; CI 95%, 1.95-8.75), no utilization of coronary stent (OR, 3.44; CI 95%, 1.71-7.37), and previous infarction (OR, 2.82; CI 95%, 1.29-5.90). CONCLUSIONS Coronary angioplasty allows a successful coronary recanalization in most patients with acute myocardial infarction. Some basic characteristics, however, may identify some subsets in which a successful angiographic result may be more difficult to obtain.
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Affiliation(s)
- R Moreno
- Departamento de Cardiología. Hospital Gregorio Marañón. Madrid
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