1
|
Chen L, Zhong J, Hong R, Chen Y, Li B, Wang L, Yan Y, Chen L, Chen Q, Luo Y. Predictive value of the inconsistency between the residual and post-PCI QFR for prognosis in PCI patients. Front Cardiovasc Med 2024; 11:1297218. [PMID: 38694566 PMCID: PMC11062415 DOI: 10.3389/fcvm.2024.1297218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 03/22/2024] [Indexed: 05/04/2024] Open
Abstract
Introduction To investigate the prognostic value of the consistency between the residual quantitative flow ratio (QFR) and postpercutaneous coronary intervention (PCI) QFR in patients undergoing revascularization. Methods This was a single-center, retrospective, observational study. All enrolled patients were divided into five groups according to the ΔQFR (defined as the value of the post-PCI QFR minus the residual QFR): (1) Overanticipated group; (2) Slightly overanticipated group; (3) Consistent group; (4) Slightly underanticipated group; and (5) Underanticipated group. The primary outcome was the 5-year target vessel failure (TVF). Results A total of 1373 patients were included in the final analysis. The pre-PCI QFR and post-PCI QFR were significantly different among the five groups. TVF within 5 years occurred in 189 patients in all the groups. The incidence of TVF was significantly greater in the underanticipated group than in the consistent group (P = 0.008), whereas no significant differences were found when comparing the underanticipated group with the other three groups. Restricted cubic spline regression analysis showed that the risk of TVF was nonlinearly related to the ΔQFR. A multivariate Cox regression model revealed that a ΔQFR≤ -0.1 was an independent risk factor for TVF. Conclusions The consistency between the residual QFR and post-PCI QFR may be associated with the long-term prognosis of patients. Patients whose post-PCI QFR is significantly lower than the residual QFR may be at greater risk of TVF. An aggressive PCI strategy for lesions is anticipated to have less functional benefit and may not result in a better clinical outcome.
Collapse
Affiliation(s)
- Lihua Chen
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Heart Medical Center, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Changle District People's Hospital Cardiovascular Department, Fuzhou, Fujian, China
| | - Jiaxin Zhong
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Heart Medical Center, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Ruijin Hong
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Heart Medical Center, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Yuxiang Chen
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Heart Medical Center, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Beilei Li
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Heart Medical Center, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Laicheng Wang
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Heart Medical Center, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Yuanming Yan
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Heart Medical Center, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Lianglong Chen
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Heart Medical Center, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Qin Chen
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Heart Medical Center, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Yukun Luo
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Heart Medical Center, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| |
Collapse
|
2
|
Akbari T, Al-Lamee R. Percutaneous coronary intervention in multi-vessel disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 44:80-91. [DOI: 10.1016/j.carrev.2022.06.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 01/09/2023]
|
3
|
Predictors of Mortality and Long-Term Outcome in Patients with Anterior STEMI: Results from a Single Center Study. J Clin Med 2021; 10:jcm10235634. [PMID: 34884341 PMCID: PMC8658372 DOI: 10.3390/jcm10235634] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 11/22/2021] [Accepted: 11/26/2021] [Indexed: 12/28/2022] Open
Abstract
Anterior ST segment elevation myocardial infarction (A-STEMI) has the worst prognosis among all infarct sites due to larger infarct size and the higher cardiac enzyme release. We retrospectively analyzed 584 A-STEMI undergoing urgent coronary angiography from October 2008 to April 2019. The median follow-up time was 1774 days with a minimum of a 1-year follow-up for 498 patients. In-hospital mortality was 8.6%, while long-term, all-cause mortality and 1-year mortality were 18.8% and 6.8%, respectively. The main predictors for in-hospital mortality were ejection fraction (LV-EF), baseline estimated glomerular filtration rate (eGFR), female gender and cardiogenic shock (CS) at admission, while long-term predictors of mortality were age, coronary artery disease (CAD) extension and LV-EF. Patients presenting with CS (6.5%) showed a higher mortality rate (in-hospital 68.4%, long term 41.7%). Among 245 patients (42%) with multivessel disease (MVD), complete revascularization (CR) during the index procedure was performed in 42.8% of patients and more often in patients with CS at admission (19.1% vs. 6.1%, p = 0.008). Short- and long-term mortality were not significantly influenced by the revascularization strategy (CR/culprit only). Our study confirmed the extreme fragility of A-STEMI patients, especially in case of CS at admission. LV-EF is a powerful predictor of a poor outcome. In MVD, CR during p-PCI did not show any advantage for either long- or short-term mortality compared to the culprit-only strategy.
Collapse
|
4
|
Rathod KS, Koganti S, Jain AK, Astroulakis Z, Lim P, Rakhit R, Kalra SS, Dalby MC, O'Mahony C, Malik IS, Knight CJ, Mathur A, Redwood S, Sirker A, MacCarthy PA, Smith EJ, Wragg A, Jones DA. Complete Versus Culprit-Only Lesion Intervention in Patients With Acute Coronary Syndromes. J Am Coll Cardiol 2019; 72:1989-1999. [PMID: 30336821 DOI: 10.1016/j.jacc.2018.07.089] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 06/29/2018] [Accepted: 07/30/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND A large proportion of patients presenting with non-ST-segment elevation myocardial infarction (NSTEMI) present with multivessel disease (MVD). There is uncertainty in the role of complete coronary revascularization in this group of patients. OBJECTIVES The aim of this study was to investigate the outcomes of complete revascularization compared with culprit vessel-only intervention in a large contemporary cohort of patients undergoing percutaneous coronary intervention (PCI) for NSTEMI. METHODS The authors undertook an observational cohort study of 37,491 NSTEMI patients treated between 2005 and 2015 at the 8 heart attack centers in London. Clinical details were recorded at the time of the procedure into local databases using the British Cardiac Intervention Society (BCIS) PCI dataset. A total of 21,857 patients (58.3%) presented with NSTEMI and MVD. Primary outcome was all-cause mortality at a median follow-up of 4.1 years (interquartile range: 2.2 to 5.8 years). RESULTS A total of 11,737 (53.7%) patients underwent single-stage complete revascularization during PCI for NSTEMI, rates that significantly increased during the study period (p = 0.006). Those patients undergoing complete revascularization were older and more likely to be male, diabetic, have renal disease and a history of previous myocardial infarction/revascularization compared with the culprit-only revascularization group. Although crude, in-hospital major adverse cardiac event rates were similar (5.2% vs. 4.8%; p = 0.462) between the 2 groups. Kaplan-Meier analysis demonstrated significant differences in mortality rates between the 2 groups (22.5% complete revascularization vs. 25.9% culprit vessel intervention; p = 0.0005) during the follow-up period. After multivariate Cox analysis (hazard ratio: 0.90; 95% confidence interval: 0.85 to 0.97) and the use of propensity matching (hazard ratio: 0.89; 95% confidence interval: 0.76 to 0.98) complete revascularization was associated with reduced mortality. CONCLUSIONS In NSTEMI patients with MVD, despite higher initial (in-hospital) mortality rates, single-stage complete coronary revascularization appears to be superior to culprit-only vessel PCI in terms of long-term mortality rates. This supports the need for further randomized study to confirm these findings.
Collapse
Affiliation(s)
| | | | - Ajay K Jain
- Barts Health NHS Trust, London, United Kingdom
| | - Zoe Astroulakis
- St. George's Healthcare NHS Foundation Trust, St. George's Hospital, London, United Kingdom
| | - Pitt Lim
- St. George's Healthcare NHS Foundation Trust, St. George's Hospital, London, United Kingdom
| | - Roby Rakhit
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | | | - Miles C Dalby
- Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, Middlesex, London, United Kingdom
| | | | - Iqbal S Malik
- Imperial College Healthcare NHS Foundation Trust, Hammersmith Hospital, London, United Kingdom
| | | | | | - Simon Redwood
- St. Thomas' NHS Foundation Trust, Guys & St. Thomas Hospital, London, United Kingdom
| | | | - Philip A MacCarthy
- Kings College Hospital, King's College Hospital NHS Foundation Trust, Denmark Hill, London, United Kingdom
| | | | | | | |
Collapse
|
5
|
Metaanalysis of Multivessel vs Culprit Artery Only Percutaneous Coronary Intervention in ST Elevation Myocardial Infarction. Ochsner J 2019; 19:107-115. [PMID: 31258422 DOI: 10.31486/toj.18.0033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: Primary percutaneous coronary intervention (PCI) is the most frequently used treatment modality for patients presenting with ST elevation myocardial infarction (STEMI). Current professional society guidelines recommend culprit artery only PCI. Recent evidence suggests the potential benefit of multivessel PCI among patients with STEMI that is not complicated by cardiogenic shock. Methods: We systematically searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials for clinical studies of patients with STEMI, not complicated by cardiogenic shock, who underwent primary PCI between January 1966 and January 2018. We evaluated all-cause and cardiovascular mortality, reinfarction, and repeat revascularization among patients randomized to a multivessel PCI strategy compared to a culprit artery only PCI strategy. Results: Four randomized clinical trials with a total of 1,044 patients met the inclusion criteria. Five hundred and sixty-six patients underwent multivessel PCI, and 478 patients underwent culprit artery only PCI. Multivessel PCI reduced all the studied endpoints: total death, cardiac death, reinfarction, and repeat revascularization (all P values <0.05). Conclusion: To our knowledge, this is the largest metaanalysis of randomized controlled trials studying multivessel PCI vs culprit artery only PCI in STEMI patients without shock, among whom lesion severity was graded by angiography alone. We found that compared to culprit artery only PCI, the multivessel PCI strategy was beneficial in reducing all-cause and cardiovascular mortality, reinfarction, and the need for repeat revascularization.
Collapse
|
6
|
Osório APS, Quadros ASD, Vieira JLDC, Portal VL. Percutaneous Intervention in ST-Elevation Myocardial Infarction: Culprit-only or Complete Revascularization? Arq Bras Cardiol 2017; 109:599-605. [PMID: 29185617 PMCID: PMC5783441 DOI: 10.5935/abc.20170174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Accepted: 07/05/2017] [Indexed: 01/25/2023] Open
Abstract
The best approach of multivessel coronary artery disease in the context of acute myocardial infarction with ST segment elevation and primary percutaneous coronary intervention is one of the main reasons for controversy in cardiology. Although the main global guidelines do not recommend routine complete revascularization in these patients, recent randomized clinical trials have demonstrated benefit of this approach in reducing cardiovascular outcomes. For this reason, an adequate review of this evidence is essential in order to establish scientifically based strategy and achieve better outcomes for these patients who present with acute myocardial infarction. This review aims to present objectively the most recent evidence available on this topic.
Collapse
Affiliation(s)
- Ana Paula Susin Osório
- Instituto de Cardiologia/Fundação Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | | | | | - Vera Lucia Portal
- Instituto de Cardiologia/Fundação Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| |
Collapse
|
7
|
Patel S, Bailey SR. Revascularization Strategies in STEMI with Multivessel Disease: Deciding on Culprit Versus Complete-Ad Hoc or Staged. Curr Cardiol Rep 2017; 19:93. [PMID: 28840487 DOI: 10.1007/s11886-017-0906-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW This review will address the clinical conundrum of those who may derive clinical benefit from complete revascularization of coronary stenosis that are discovered at the time of ST segment elevation myocardial infarction (STEMI). The decision to revascularize additional vessels with angiographic stenosis beyond the culprit lesion remains controversial, as does the timing of revascularization. RECENT FINDINGS STEMI patients represent a high-risk patient population that have up to a 50% prevalence of multivessel disease. Multivessel disease represents an important risk factor for short- and long-term morbidity and mortality. Potential benefits of multivessel PCI for STEMI might include reduced short- and long-term mortality, revascularization, reduced resource utilization, and costs. Which population will benefit and what the optimal timing of revascularization in the peri-MI period remains controversial. Consideration of multivessel revascularization in the setting of STEMI may occur in up to one half of STEMI patients. Evaluation of the comorbidities including diabetes, extent of myocardium at risk, lesion complexity, ventricular function, and risk factors for complications such as contrast induced nephropathy which is important in determining the appropriate care pathway.
Collapse
Affiliation(s)
- Shalin Patel
- From the Janey Briscoe Center of Excellence for Cardiovascular Research, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78232, USA
| | - Steven R Bailey
- From the Janey Briscoe Center of Excellence for Cardiovascular Research, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78232, USA.
| |
Collapse
|
8
|
Vogel B, Mehta SR, Mehran R. Reperfusion strategies in acute myocardial infarction and multivessel disease. Nat Rev Cardiol 2017; 14:665-678. [DOI: 10.1038/nrcardio.2017.88] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
|
9
|
Barton GR, Irvine L, Flather M, McCann GP, Curzen N, Gershlick AH. Economic Evaluation of Complete Revascularization for Patients with Multivessel Disease Undergoing Primary Percutaneous Coronary Intervention. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:745-751. [PMID: 28577691 DOI: 10.1016/j.jval.2017.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 01/25/2017] [Accepted: 02/06/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To determine the cost-effectiveness of complete revascularization at index admission compared with infarct-related artery (IRA) treatment only, in patients with multivessel disease undergoing primary percutaneous coronary intervention (P-PCI) for ST-segment elevation myocardial infarction. METHODS An economic evaluation of a multicenter randomized trial was conducted, comparing complete revascularization at index admission to IRA-only P-PCI in patients with multivessel disease (12-month follow-up). Overall hospital costs (costs for P-PCI procedure(s), hospital length of stay, and any subsequent re-admissions) were estimated. Outcomes were major adverse cardiac events (MACEs, a composite of all-cause death, recurrent myocardial infarction, heart failure, and ischemia-driven revascularization) and quality-adjusted life-years (QALYs) derived from the three-level EuroQol five-dimensional questionnaire. Multiple imputation was undertaken. The mean incremental cost and effect, with associated 95% confidence intervals, the incremental cost-effectiveness ratio, and the cost-effectiveness acceptability curve were estimated. RESULTS On the basis of 296 patients, the mean incremental overall hospital cost for complete revascularization was estimated to be -£215.96 (-£1390.20 to £958.29), compared with IRA-only, with a per-patient mean reduction in MACEs of 0.170 (0.044 to 0.296) and a QALY gain of 0.011 (-0.019 to 0.041). According to the cost-effectiveness acceptability curve, the probability of complete revascularization being cost-effective was estimated to be 72.0% at a willingness-to-pay threshold value of £20,000 per QALY. CONCLUSIONS Complete revascularization at index admission was estimated to be more effective (in terms of MACEs and QALYs) and cost-effective (overall costs were estimated to be lower and complete revascularization thereby dominated IRA-only). There was, however, some uncertainty associated with this decision.
Collapse
Affiliation(s)
- Garry R Barton
- Norwich Medical School, University of East Anglia, Norwich, UK.
| | - Lisa Irvine
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; NIHR Leicester Cardiovascular Biomedical Research Unit, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK
| | - Nick Curzen
- University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine, University of Southampton, Southampton, UK
| | - Anthony H Gershlick
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; NIHR Leicester Cardiovascular Biomedical Research Unit, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK
| |
Collapse
|
10
|
Gaffar R, Habib B, Filion KB, Reynier P, Eisenberg MJ. Optimal Timing of Complete Revascularization in Acute Coronary Syndrome: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2017; 6:JAHA.116.005381. [PMID: 28396570 PMCID: PMC5533029 DOI: 10.1161/jaha.116.005381] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Studies have suggested that complete revascularization is superior to culprit‐only revascularization for the treatment of enzyme‐positive acute coronary syndrome. However, the optimal timing of complete revascularization remains unclear. We conducted a systematic review and meta‐analysis of randomized controlled trials comparing single‐stage complete revascularization with multistage percutaneous coronary intervention in patients with ST‐segment elevation myocardial infarction or non–ST‐segment elevation myocardial infarction with multivessel disease. Methods and Results We systematically searched the Cochrane Central Register of Controlled Trials, Embase, PubMed, and MEDLINE for randomized controlled trials comparing single‐stage complete revascularization with multistage revascularization in patients with enzyme‐positive acute coronary syndrome. The primary outcome was the incidence of major adverse cardiovascular events at longest follow‐up. Data were pooled using DerSimonian and Laird random‐effects models. Four randomized controlled trials (n=838) were included in our meta‐analysis. The risk of unplanned repeat revascularization at longest follow‐up was significantly lower in patients randomized to single‐stage complete revascularization (risk ratio, 0.68; 95% CI, 0.47–0.99). Results also suggest a trend towards lower risks of major adverse cardiovascular events for patients randomized to single‐stage revascularization at 6 months (risk ratio, 0.67; 95% CI, 0.40–1.11) and at longest follow‐up (risk ratio, 0.79; 95% CI, 0.52–1.20). Risks of mortality and recurrent myocardial infarction at longest follow‐up were also lower with single‐stage revascularization, but 95% CIs were wide and included unity. Conclusions Our results suggest that single‐stage complete revascularization is safe. There also appears to be a trend towards lower long‐term risks of mortality and major adverse cardiovascular events; however, additional randomized controlled trials are required to confirm the potential benefits of single‐stage multivessel percutaneous coronary intervention.
Collapse
Affiliation(s)
- Rouan Gaffar
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Bettina Habib
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Kristian B Filion
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Departments of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Pauline Reynier
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Mark J Eisenberg
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada .,Division of Cardiology, Jewish General Hospital, Montreal, Quebec, Canada.,Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Departments of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
11
|
Zhao B, Peng J, Ren L, Lei L, Wang Z, Ye H. Conservative pharmacotherapy vs. staged percutaneous coronary intervention for non-culprit vessels in patients with ST-segment elevation myocardial infarction. Exp Ther Med 2017; 12:4147-4153. [PMID: 28105141 DOI: 10.3892/etm.2016.3895] [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: 11/25/2015] [Accepted: 09/09/2016] [Indexed: 11/05/2022] Open
Abstract
The present study aimed to compare the effect of conservative pharmacotherapy (CP) and staged percutaneous coronary intervention (SPCI) on significant non-culprit vessels in patients with ST-segment elevation myocardial infarction (STEMI). A total of 266 male and 40 female patients were divided into two groups following their first successful PCI treatment: i) Patients in the complete revascularization (CR) group undergoing SPCI; and ii) patients in the CP group undergoing CP. Follow-up data were collected at 180 or 360 days after surgery to compare the rates of major adverse cardiovascular events (MACE), recurrent myocardial infarction, recurrent angina pectoris and MACE-free survival rates between the two groups. The rate of MACE in the CP group was higher compared with that in the CR group at the 360-day follow-up (6.1 vs. 12.7%; P=0.05), and the same was reflected in the rate of recurrent myocardial infarction (10.1 vs. 4.1%; P=0.04). The rate of recurrent angina pectoris in the CP group was significantly higher compared with that in CR group at the 180-day (13.9 vs. 5.4%; P=0.012) and 360-day follow-up (18.4 vs. 8.1%; P=0.009). The MACE-free survival rate of patients was significantly higher in the CR group compared with that in the CP group at the 360-day follow-up (93.9% vs. 87.3%, P<0.05). In conclusion, the SPCI of non-culprit vessels in patients with STEMI is associated with better clinical outcomes than CP.
Collapse
Affiliation(s)
- Bo Zhao
- Department of Cardiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, P.R. China
| | - Jianjun Peng
- Department of Cardiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, P.R. China
| | - Lihui Ren
- Department of Cardiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, P.R. China
| | - Licheng Lei
- Department of Cardiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, P.R. China
| | - Zuoyan Wang
- Department of Cardiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, P.R. China
| | - Huiming Ye
- Department of Cardiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, P.R. China
| |
Collapse
|
12
|
Nagaraja V, Ooi SY, Nolan J, Large A, De Belder M, Ludman P, Bagur R, Curzen N, Matsukage T, Yoshimachi F, Kwok CS, Berry C, Mamas MA. Impact of Incomplete Percutaneous Revascularization in Patients With Multivessel Coronary Artery Disease: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2016; 5:JAHA.116.004598. [PMID: 27986755 PMCID: PMC5210416 DOI: 10.1161/jaha.116.004598] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Up to half of patients undergoing percutaneous coronary intervention have multivessel coronary artery disease (MVD) with conflicting data regarding optimal revascularization strategy in such patients. This paper assesses the evidence for complete revascularization (CR) versus incomplete revascularization in patients undergoing percutaneous coronary intervention, and its prognostic impact using meta‐analysis. Methods and Results A search of PubMed, EMBASE, MEDLINE, Current Contents Connect, Google Scholar, Cochrane library, Science Direct, and Web of Science was conducted to identify the association of CR in patients with multivessel coronary artery disease undergoing percutaneous coronary intervention with major adverse cardiac events and mortality. Random‐effects meta‐analysis was used to estimate the odds of adverse outcomes. Meta‐regression analysis was conducted to assess the relationship with continuous variables and outcomes. Thirty‐eight publications that included 156 240 patients were identified. Odds of death (OR 0.69, 95% CI 0.61‐0.78), repeat revascularization (OR 0.60, 95% CI 0.45‐0.80), myocardial infarction (OR 0.64, 95% CI 0.50‐0.81), and major adverse cardiac events (OR 0.63, 95% CI 0.50‐0.79) were significantly lower in the patients who underwent CR. These outcomes were unchanged on subgroup analysis regardless of the definition of CR. Similar findings were recorded when CR was studied in the chronic total occlusion (CTO) subgroup (OR 0.65, 95% CI 0.53‐0.80). A meta‐regression analysis revealed a negative relationship between the OR for mortality and the percentage of CR. Conclusion CR is associated with reduced risk of mortality and major adverse cardiac events, irrespective of whether an anatomical or a score‐based definition of incomplete revascularization is used, and this magnitude of risk relates to degree of CR. These results have important implications for the interventional management of patients with multivessel coronary artery disease.
Collapse
Affiliation(s)
- Vinayak Nagaraja
- Department of Cardiology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Sze-Yuan Ooi
- Department of Cardiology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - James Nolan
- Royal Stoke University Hospital, University Hospitals of North Midlands, Stoke-on-Trent, United Kingdom.,Keele Cardiovascular Research Group, Institute of Science and Technology in Medicine, University of Keele, Stoke-on-Trent, United Kingdom
| | - Adrian Large
- Royal Stoke University Hospital, University Hospitals of North Midlands, Stoke-on-Trent, United Kingdom
| | - Mark De Belder
- The James Cook University Hospital, Middlesbrough, United Kingdom
| | - Peter Ludman
- Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Rodrigo Bagur
- Division of Cardiology, Department of Medicine and Department of Epidemiology & Biostatistics, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Nick Curzen
- University Hospital Southampton & Faculty of Medicine University of Southampton, United Kingdom
| | - Takashi Matsukage
- Division of Cardiology, Tokai University School of Medicine, Isehara, Japan
| | | | - Chun Shing Kwok
- Royal Stoke University Hospital, University Hospitals of North Midlands, Stoke-on-Trent, United Kingdom.,Keele Cardiovascular Research Group, Institute of Science and Technology in Medicine, University of Keele, Stoke-on-Trent, United Kingdom
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom
| | - Mamas A Mamas
- Royal Stoke University Hospital, University Hospitals of North Midlands, Stoke-on-Trent, United Kingdom .,Keele Cardiovascular Research Group, Institute of Science and Technology in Medicine, University of Keele, Stoke-on-Trent, United Kingdom
| |
Collapse
|
13
|
Villablanca PA, Briceno DF, Massera D, Hlinomaz O, Lombardo M, Bortnick AE, Menegus MA, Pyo RT, Garcia MJ, Mookadam F, Ramakrishna H, Wiley J, Faggioni M, Dangas GD. Culprit-lesion only versus complete multivessel percutaneous intervention in ST-elevation myocardial infarction: A systematic review and meta-analysis of randomized trials. Int J Cardiol 2016; 220:251-9. [DOI: 10.1016/j.ijcard.2016.06.098] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 06/11/2016] [Accepted: 06/21/2016] [Indexed: 11/25/2022]
|
14
|
Bates ER, Tamis-Holland JE, Bittl JA, O’Gara PT, Levine GN. PCI Strategies in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Artery Disease. J Am Coll Cardiol 2016; 68:1066-81. [DOI: 10.1016/j.jacc.2016.05.086] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/19/2016] [Accepted: 05/10/2016] [Indexed: 12/19/2022]
|
15
|
Di Pasquale G, Filippini E, Pavesi PC, Tortorici G, Casella G, Sangiorgio P. Complete versus culprit-only revascularization in ST-elevation myocardial infarction and multivessel disease. Intern Emerg Med 2016; 11:499-506. [PMID: 26951188 DOI: 10.1007/s11739-016-1419-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 02/18/2016] [Indexed: 02/04/2023]
Abstract
In 30-60 % of patients presenting with ST-segment elevation myocardial infarction (STEMI), significant stenoses are present in one or more non-infarct-related arteries (IRA). This correlates with an increased risk of major adverse cardiac events (MACE). Current guidelines, do not recommend revascularization of non-culprit lesions unless complicated by cardiogenic shock or persistent ischemia after primary percutaneous coronary intervention (PCI). Prior observational and small randomized controlled trials (RCTs) have demonstrated conflicting results regarding the optimal revascularization strategy in STEMI patients with multivessel disease. Recently, randomized studies (PRAMI, CvLPRIT, and DANAMI 3-PRIMULTI) provide encouraging data that suggest potential benefit with complete revascularization in STEMI patients with obstructive non-culprit lesions. Differently, in the PRAGUE-13 trial there were no differences in MACE between complete revascularization and culprit-only PCI. Several meta-analyses were recently published including randomized and non-randomized clinical trials, showing different results depending on the included trials. In conclusion, the current available evidence from the randomized clinical trials, with a total sample size of only 2000 patients, is not robust enough to firmly recommend complete revascularization in STEMI patients. This uncertainty lends support to the continuation of the COMPLETE trial. This ongoing trial is anticipated to enroll 3900 patients with STEMI from across the world, and will be powered for the hard outcomes of death and myocardial infarction. Until the results of the COMPLETE trial are reported, physicians need to individualize care regarding the opportunity and the timing of the non-IRA PCI.
Collapse
Affiliation(s)
- Giuseppe Di Pasquale
- Division of Cardiology, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy.
| | - Elisa Filippini
- Division of Cardiology, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Pier Camillo Pavesi
- Division of Cardiology, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Gianfranco Tortorici
- Division of Cardiology, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Gianni Casella
- Division of Cardiology, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Pietro Sangiorgio
- Division of Cardiology, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy
| |
Collapse
|
16
|
Engstrøm T, Kelbæk H, Helqvist S, Høfsten DE, Kløvgaard L, Holmvang L, Jørgensen E, Pedersen F, Saunamäki K, Clemmensen P, De Backer O, Ravkilde J, Tilsted HH, Villadsen AB, Aarøe J, Jensen SE, Raungaard B, Køber L. Complete revascularisation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multivessel disease (DANAMI-3—PRIMULTI): an open-label, randomised controlled trial. Lancet 2015; 386:665-71. [PMID: 26347918 DOI: 10.1016/s0140-6736(15)60648-1] [Citation(s) in RCA: 676] [Impact Index Per Article: 75.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with acute ST-segment elevation myocardial infarction (STEMI) and multivessel coronary disease have a worse prognosis compared with individuals with single-vessel disease. We aimed to study the clinical outcome of patients with STEMI treated with fractional flow reserve (FFR)-guided complete revascularisation versus treatment of the infarct-related artery only. METHODS We undertook an open-label, randomised controlled trial at two university hospitals in Denmark. Patients presenting with STEMI who had one or more clinically significant coronary stenosis in addition to the lesion in the infarct-related artery were included. After successful percutaneous coronary intervention (PCI) of the infarct-related artery, patients were randomly allocated (in a 1:1 ratio) either no further invasive treatment or complete FFR-guided revascularisation before discharge. Randomisation was done electronically via a web-based system in permuted blocks of varying size by the clinician who did the primary PCI. All patients received best medical treatment. The primary endpoint was a composite of all-cause mortality, non-fatal reinfarction, and ischaemia-driven revascularization of lesions in non-infarct-related arteries and was assessed when the last enrolled patient had been followed up for 1 year. Analysis was on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov, number NCT01960933. FINDINGS From March, 2011, to February, 2014, we enrolled 627 patients to the trial; 313 were allocated no further invasive treatment after primary PCI of the infarct-related artery only and 314 were assigned complete revascularization guided by FFR values. Median follow-up was 27 months (range 12–44 months). Events comprising the primary endpoint were recorded in 68 (22%) patients who had PCI of the infarct-related artery only and in 40 (13%) patients who had complete revascularisation (hazard ratio 0∙56, 95% CI 0∙38–0∙83; p=0∙004). INTERPRETATION In patients with STEMI and multivessel disease, complete revascularisation guided by FFR measurements significantly reduces the risk of future events compared with no further invasive intervention after primary PCI. This effect is driven by significantly fewer repeat revascularisations, because all-cause mortality and non-fatal reinfarction did not differ between groups. Thus, to avoid repeat revascularisation, patients can safely have all their lesions treated during the index admission. Future studies should clarify whether complete revascularization should be done acutely during the index procedure or at later time and whether it has an effect on hard endpoints. FUNDING Danish Agency for Science, Technology and Innovation and Danish Council for Strategic Research.
Collapse
|
17
|
Influence of multivessel disease with or without additional revascularization on mortality in patients with ST-segment elevation myocardial infarction. Am Heart J 2015; 170:70-8. [PMID: 26093866 DOI: 10.1016/j.ahj.2015.03.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 03/18/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND In patients with ST-segment elevation myocardial infarction (STEMI), timely reperfusion with primary percutaneous coronary intervention (PCI) is the preferred treatment. In primary PCI patients with multivessel disease, it is unclear whether culprit vessel PCI only is the preferred treatment. We compared mortality among (1) STEMI patients with single-vessel disease and those with multivessel disease and (2) multivessel disease patients with and without additional revascularization of nonculprit lesions within 2 months after the index PCI. METHODS From January 2002 to June 2009, all patients presenting with STEMI and treated with primary PCI were identified from the Western Denmark Heart Registry, which covers a population of 3.0 million. The hazard ratio (HR) for death was estimated using a Cox regression model, controlling for potential confounding. RESULTS The study cohort consisted of 8,822 patients: 4,770 (54.1%) had single-vessel disease and 4,052 (45.9%) had multivessel disease. Overall, 1-year cumulative mortality was 7.6%, and 7-year cumulative mortality was 24.0%. Multivessel disease was associated with higher 7-year mortality (adjusted HR 1.45 [95% CI 1.30-1.62], P < .001). Among patients with multivessel disease, lack of additional revascularization beyond the culprit lesion was associated with higher 7-year mortality (adjusted HR 1.50 [95% CI 1.25-1.80], P < .001). In patients with multivessel disease who underwent additional revascularization, 7-year mortality (adjusted HR 1.01 [95% CI 0.84-1.22], P = .89) was similar compared to patients with single-vessel disease. CONCLUSION In STEMI patients, multivessel disease was associated with a higher mortality compared to single-vessel disease. In multivessel disease patients, additional revascularization was associated with a higher survival compared with culprit vessel PCI only.
Collapse
|
18
|
Harries I, Ramcharitar S. Total revascularization of coronary disease at the time of primary percutaneous coronary intervention. Future Cardiol 2014; 10:451-5. [DOI: 10.2217/fca.14.30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Iwan Harries
- Wiltshire Cardiac Centre, Department of Interventional Cardiology, Marlborough Road, Swindon, SN3 6BB, UK
| | - Steve Ramcharitar
- Wiltshire Cardiac Centre, Department of Interventional Cardiology, Marlborough Road, Swindon, SN3 6BB, UK
| |
Collapse
|
19
|
Jeger R, Jaguszewski M, Nallamothu BN, Lüscher TF, Urban P, Pedrazzini GB, Erne P, Radovanovic D. Acute multivessel revascularization improves 1-year outcome in ST-elevation myocardial infarction. Int J Cardiol 2014; 172:76-81. [DOI: 10.1016/j.ijcard.2013.12.083] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 11/26/2013] [Accepted: 12/20/2013] [Indexed: 10/25/2022]
|
20
|
Percutaneous coronary intervention for nonculprit vessels in cardiogenic shock complicating ST-segment elevation acute myocardial infarction. Crit Care Med 2014; 42:17-25. [PMID: 24105454 DOI: 10.1097/ccm.0b013e3182a2701d] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES We investigated the clinical impact of multivessel percutaneous coronary intervention in ST-segment elevation myocardial infarction complicated by cardiogenic shock with multivessel disease. DESIGN A prospective, multicenter, observational study. SETTING Cardiac ICU of a university hospital. PATIENTS Between November 2005 and September 2010, 338 patients were selected. Inclusion criteria were as follows: 1) ST-segment elevation myocardial infarction with cardiogenic shock and 2) multivessel disease with successful primary percutaneous coronary intervention for the infarct-related artery. Patients were divided into multivessel percutaneous coronary intervention and culprit-only percutaneous coronary intervention. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Primary outcome was all-cause mortality. Median follow-up duration was 224 days (interquartile range, 46-383 d). Multivessel percutaneous coronary intervention was performed during the primary percutaneous coronary intervention in 60 patients (17.8%). In-hospital mortality was similar in both groups (multivessel percutaneous coronary intervention vs culprit-only percutaneous coronary intervention, 31.7% vs 24.5%; p = 0.247). All-cause mortality during follow-up was not significantly different between the two groups after adjusting for patient, angiographic, and procedural characteristics as well as propensity scores for receiving multivessel percutaneous coronary intervention (35.0% vs 30.6%; adjusted hazard ratio, 1.06; 95% CI, 0.61-1.86; p = 0.831). There were no significant differences between the groups in rates of major adverse cardiac events (41.7% vs 37.1%; adjusted hazard ratio, 1.03; 95% CI, 0.62-1.71; p = 0.908) and any revascularization (6.7% vs 4.7%; adjusted hazard ratio, 1.88; 95% CI, 0.51-6.89; p = 0.344). CONCLUSIONS Multivessel percutaneous coronary intervention could not reduce the prevalence of mortality in patients with cardiogenic shock complicating ST-segment elevation myocardial infarction and multivessel disease during primary percutaneous coronary intervention.
Collapse
|
21
|
Pandit A, Aryal MR, Aryal Pandit A, Hakim FA, Giri S, Mainali NR, Sharma P, Lee HR, Fortuin FD, Mookadam F. Preventive PCI versus culprit lesion stenting during primary PCI in acute STEMI: a systematic review and meta-analysis. Open Heart 2014; 1:e000012. [PMID: 25332779 PMCID: PMC4189298 DOI: 10.1136/openhrt-2013-000012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 01/22/2014] [Accepted: 01/25/2014] [Indexed: 11/09/2022] Open
Abstract
Aim The benefit of preventive percutaneous coronary intervention (PCI) in ST elevation myocardial infarction (STEMI) has been shown in randomised trials. However, all the randomised trials are underpowered to detect benefit in cardiac death. We aim to systematically review evidence on the cardiac mortality benefit of preventive PCI in patients presenting with acute STEMI in randomised patient populations. Methods PubMed, Scopus, Cochrane and clinicaltrials.gov databases were searched for studies published until 30 September 2013. The studies were limited to randomised clinical trials. Independent observers abstracted the data on outcomes, characteristics and qualities of studies included. Fixed effect model was employed for meta-analysis. Heterogeneity of studies included was analysed using I2 statistics. Results In three randomised clinical trials published, involving 748 patients with acute STEMI and multivessel disease, 416 patients were randomised to preventive PCI and 332 to culprit-only PCI. Patients undergoing preventive PCI had significant lower risk of cardiovascular deaths (pooled OR 0.39, 95% CI 0.18 to 0.83, p=0.01, I2=0%), repeat revascularisation (pooled OR 0.28, 95% CI 0.18 to 0.44, p=0.00001, I2=0%) and non-fatal myocardial infarction (pooled OR 0.38, 95% CI 0.20 to 0.75, p=0.005, I2=0%) compared with culprit-only revascularisation. Conclusions In patients presenting with acute STEMI and significant multivessel coronary artery disease, based on our data, preventive PCI is associated with lower risk of cardiovascular mortality compared with primary PCI of only the culprit artery. This finding needs to be confirmed in larger adequately powered randomised clinical trials.
Collapse
Affiliation(s)
- Anil Pandit
- Division of Cardiovascular Diseases , Mayo Clinic , Scottsdale, Arizona , USA
| | - Madan Raj Aryal
- Department of Internal Medicine , Reading Hospital , West Reading, Pennsylvania , USA
| | | | - Fayaz Ahmad Hakim
- Division of Cardiovascular Diseases , Mayo Clinic , Scottsdale, Arizona , USA
| | - Smith Giri
- Department of Internal Medicine , University of Tennessee , Memphis, Tennessee , USA
| | - Naba Raj Mainali
- Department of Internal Medicine , Reading Hospital , West Reading, Pennsylvania , USA
| | - Prashant Sharma
- Department of Internal Medicine , Mayo Clinic , Rochester, Minnesota , USA
| | - Howard R Lee
- Division of Cardiovascular Diseases , Mayo Clinic , Scottsdale, Arizona , USA
| | - F David Fortuin
- Division of Cardiovascular Diseases , Mayo Clinic , Scottsdale, Arizona , USA
| | - Farouk Mookadam
- Division of Cardiovascular Diseases , Mayo Clinic , Scottsdale, Arizona , USA
| |
Collapse
|
22
|
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
| | | | | | | |
Collapse
|
23
|
Jaguszewski M, Radovanovic D, Nallamothu BK, Lüscher TF, Urban P, Eberli FR, Bertel O, Pedrazzini GB, Windecker S, Jeger R, Erne P. Multivessel versus culprit vessel percutaneous coronary intervention in ST-elevation myocardial infarction: is more worse? EUROINTERVENTION 2013; 9:909-915. [DOI: 10.4244/eijv9i8a153] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
|
24
|
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.
Collapse
|
25
|
Kelly DJ, McCann GP, Blackman D, Curzen NP, Dalby M, Greenwood JP, Fairbrother K, Shipley L, Kelion A, Heatherington S, Khan JN, Nazir S, Alahmar A, Flather M, Swanton H, Schofield P, Gunning M, Hall R, Gershlick AH. Complete Versus culprit-Lesion only PRimary PCI Trial (CVLPRIT): a multicentre trial testing management strategies when multivessel disease is detected at the time of primary PCI: rationale and design. EUROINTERVENTION 2013; 8:1190-8. [PMID: 23425543 DOI: 10.4244/eijv8i10a183] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Primary percutaneous coronary intervention (PPCI) is the preferred strategy for acute ST-segment elevation myocardial infarction (STEMI), with evidence of improved clinical outcomes compared to fibrinolytic therapy. However, there is no consensus on how best to manage multivessel coronary disease detected at the time of PPCI, with little robust data on best management of angiographically significant stenoses detected in non-infarct-related (N-IRA) coronary arteries. CVLPRIT will determine the optimal management of N-IRA lesions detected during PPCI. METHODS AND RESULTS CVLPRIT (Complete Versus culprit-Lesion only PRimary PCI Trial) is an open-label, prospective, randomised, multicentre trial. STEMI patients undergo verbal "assent" on presentation. Patients are included when angiographic MVD has been detected, and randomised to culprit (IRA)-only PCI (n=150) or in-patient complete multivessel PCI (n=150). Cumulative major adverse cardiac events (MACE) - all-cause mortality, recurrent MI, heart failure, need for revascularisation (PCI or CABG) will be recorded at 12 months. Secondary endpoints include safety endpoints of confirmed ischaemic stroke, intracranial haemorrhage, major non-intracranial bleeding, and repair of vascular complications. A cardiac magnetic resonance (CMR) substudy will provide mechanistic data on infarct size, myocardial salvage index and microvascular obstruction. A cost efficacy analysis will be undertaken. CONCLUSIONS The management of multivessel coronary artery disease in the setting of PPCI for STEMI, including the timing of when to perform non-culprit-artery revascularisation if undertaken, remains unresolved. CVLPRIT will yield mechanistic insights into the myocardial consequence of N-IRA intervention undertaken during the peri-infarct period.
Collapse
Affiliation(s)
- Damian J Kelly
- Department of Cardiology, University Hospitals of Leicester, Leicester, United Kingdom
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
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.
Collapse
Affiliation(s)
- Cong Lu
- Division of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | | | | | | | | | | | | |
Collapse
|
27
|
Tabone X. [Primary coronary angioplasty for myocardial infarction--the view of the cardiologic surgeon]. Ann Cardiol Angeiol (Paris) 2012; 61:352-356. [PMID: 23098611 DOI: 10.1016/j.ancard.2012.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 09/05/2012] [Indexed: 06/01/2023]
Abstract
The aim of this article is not to present a general academic review on primary angioplasty in patients with ST-elevation myocardial infarction, but rather to focus on some practical points that directly concern cardiologists who perform primary percutaneous interventions in these patients. We detail recent data about the use of the radial artery approach, thromboaspiration, new oral inhibitors of P2Y12, selective use of anti-GPIIb/IIIa, high dose of peri-procedural statin therapy, choice of the best stent, and the best approach for treating non-culprit lesions in patients with multivessel coronary artery disease. The changes observed in the overall management of patients undergoing primary PCI for ST-elevation myocardial infarction are likely to have participated in the decrease in mortality observed in several registries. New European guidelines on the management of STEMI, taking into account these diverse aspects, have just been published.
Collapse
Affiliation(s)
- X Tabone
- Service de cardiologie, hôpital Jacques-Cœur à Bourges, 145, avenue François-Mitterrand, 18020 Bourges cedex, France.
| |
Collapse
|
28
|
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]
|
29
|
Vlaar PJ, Mahmoud KD, Holmes DR, van Valkenhoef G, Hillege HL, van der Horst ICC, Zijlstra F, de Smet BJGL. Culprit vessel only versus multivessel and staged percutaneous coronary intervention for multivessel disease in patients presenting with ST-segment elevation myocardial infarction: a pairwise and network meta-analysis. J Am Coll Cardiol 2011; 58:692-703. [PMID: 21816304 DOI: 10.1016/j.jacc.2011.03.046] [Citation(s) in RCA: 203] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Revised: 02/28/2011] [Accepted: 03/01/2011] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The purposes of this study were to investigate whether, in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD), percutaneous coronary intervention (PCI) should be confined to the culprit or also nonculprit vessels and, when performing PCI for nonculprit vessels, whether it should take place during primary PCI or staged procedures. BACKGROUND A significant percentage of STEMI patients have MVD. However, the best PCI strategy for nonculprit vessel lesions is unknown. METHODS Pairwise and network meta-analyses were performed on 3 PCI strategies for MVD in STEMI patients: 1) culprit vessel only PCI strategy (culprit PCI), defined as PCI confined to culprit vessel lesions only; 2) multivessel PCI strategy (MV-PCI), defined as PCI of culprit vessel as well as ≥1 nonculprit vessel lesions; and 3) staged PCI strategy (staged PCI), defined as PCI confined to culprit vessel, after which ≥1 nonculprit vessel lesions are treated during staged procedures. Prospective and retrospective studies were included when research subjects were patients with STEMI and MVD undergoing PCI. The primary endpoint was short-term mortality. RESULTS Four prospective and 14 retrospective studies involving 40,280 patients were included. Pairwise meta-analyses demonstrated that staged PCI was associated with lower short- and long-term mortality as compared with culprit PCI and MV-PCI and that MV-PCI was associated with highest mortality rates at both short- and long-term follow-up. In network analyses, staged PCI was also consistently associated with lower mortality. CONCLUSIONS This meta-analysis supports current guidelines discouraging performance of multivessel primary PCI for STEMI. When significant nonculprit vessel lesions are suitable for PCI, they should only be treated during staged procedures.
Collapse
Affiliation(s)
- Pieter J Vlaar
- Department of Cardiology, Thorax Center, University Medical Center Groningen, Groningen, The Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|
30
|
Takagi H, Umemoto T. Multi- versus single-vessel percutaneous coronary intervention for ST-elevation myocardial infarction with multi-vessel disease. Int J Cardiol 2011; 152:97-9. [DOI: 10.1016/j.ijcard.2011.05.093] [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: 03/06/2011] [Revised: 05/14/2011] [Accepted: 05/14/2011] [Indexed: 10/18/2022]
|
31
|
Bittl JA. Interventional Strategies for ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Artery Disease. J Am Coll Cardiol 2011; 58:712-4. [PMID: 21816306 DOI: 10.1016/j.jacc.2011.01.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 01/13/2011] [Indexed: 11/29/2022]
|
32
|
Di Mario C. Culprit or multivessel treatment for STEMI: the opinion of a repented principal investigator. Catheter Cardiovasc Interv 2011; 77:171-3. [PMID: 21290552 DOI: 10.1002/ccd.22968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
33
|
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.
Collapse
Affiliation(s)
- Petr Widimsky
- Cardiocenter, Third Faculty of Medicine, Charles University Prague, Hospital Kralovske Vinohrady, Prague 10, Czech Republic.
| | | |
Collapse
|