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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]
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Cadore JC, Furtado MV, Tumelero R, Tognon A, Krepsky AM, Cadore D, Ruschel KB, Bedin JC, Conte T, Polanczyk CA. Complete Revascularization Versus Treatment of the Culprit Artery Only in ST Elevation Myocardial Infarction: A Multicenter Registry. Arq Bras Cardiol 2020; 115:229-237. [PMID: 32876190 PMCID: PMC8384275 DOI: 10.36660/abc.20180346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 06/14/2019] [Accepted: 08/18/2019] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Data on the management and prognosis of patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease are limited in Brazil, showing that the available revascularization strategies should be investigated. OBJECTIVE To assess the outcomes of complete revascularization versus treatment of the culprit artery only in patients with STEMI and multivessel disease. METHODS A prospective cohort study was conducted at two medical centers in southern Brazil with a 1-year follow-up after the index procedure. The primary outcome was a composite of cardiac death, reinfarction, or recurrent angina, while the secondary outcome was stroke, nonfatal cardiac arrest, major bleeding, or need for reintervention. The probability of outcomes occurring was compared between the groups using binary logistic regression. A p-value < 0.05 was considered statistically significant. RESULTS Eighty-five patients were included. Their mean age was 62±12 years, and 61 (71.8%) were male. Fifty-eight (68.2%) were treated with complete revascularization and 27 (31.8%) with incomplete revascularization. The chance of both the primary and secondary outcomes occurring was significantly greater among patients treated with incomplete revascularization when compared to those treated with complete revascularization (odds ratio [OR] 5.1, 95% confidence interval [CI] 1.6-16.1 vs. OR 5.2, 95% CI 1.2-22.9, respectively), as well as cardiac death (OR 6.4, 95% CI 1.2-35.3). CONCLUSION Registry data from two centers in southern Brazil demonstrate that the complete revascularization strategy is associated with a significant reduction in primary and secondary outcomes in a 1-year follow-up when compared to the incomplete revascularization strategy (Arq Bras Cardiol. 2020; 115(2):229-237).
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Affiliation(s)
- Julia Cremona Cadore
- Universidade Federal do Rio Grande do SulPPG Ciências Cardiovasculares: CardiologiaPorto AlegreRSBrasilUniversidade Federal do Rio Grande do Sul - PPG Ciências Cardiovasculares: Cardiologia, Porto Alegre, RS - Brasil
| | - Mariana Vargas Furtado
- Hospital de Clínicas de Porto AlegreInstituto de Avaliação de Tecnologia em SaúdePorto AlegreRSBrasilHospital de Clínicas de Porto Alegre - Instituto de Avaliação de Tecnologia em Saúde, Porto Alegre, RS - Brasil
| | - Rogério Tumelero
- Associação Hospitalar Beneficente São Vicente de PauloPasso FundoRSBrasilAssociação Hospitalar Beneficente São Vicente de Paulo, Passo Fundo, RS - Brasil
| | - Alexandre Tognon
- Associação Hospitalar Beneficente São Vicente de PauloPasso FundoRSBrasilAssociação Hospitalar Beneficente São Vicente de Paulo, Passo Fundo, RS - Brasil
| | - Ana Maria Krepsky
- Universidade Federal do Rio Grande do SulPPG Ciências Cardiovasculares: CardiologiaPorto AlegreRSBrasilUniversidade Federal do Rio Grande do Sul - PPG Ciências Cardiovasculares: Cardiologia, Porto Alegre, RS - Brasil
| | - Denis Cadore
- Associação Hospitalar Beneficente São Vicente de PauloPasso FundoRSBrasilAssociação Hospitalar Beneficente São Vicente de Paulo, Passo Fundo, RS - Brasil
| | - Karen Brasil Ruschel
- Hospital de Clínicas de Porto AlegreInstituto de Avaliação de Tecnologia em SaúdePorto AlegreRSBrasilHospital de Clínicas de Porto Alegre - Instituto de Avaliação de Tecnologia em Saúde, Porto Alegre, RS - Brasil
| | - Julia Caldas Bedin
- Universidade Federal do Rio Grande do SulFaculdade de MedicinaPorto AlegreRSBrasilUniversidade Federal do Rio Grande do Sul - Faculdade de Medicina, Porto Alegre, RS - Brasil
| | - Thais Conte
- Universidade Federal do Rio Grande do SulFaculdade de MedicinaPorto AlegreRSBrasilUniversidade Federal do Rio Grande do Sul - Faculdade de Medicina, Porto Alegre, RS - Brasil
| | - Carisi Anne Polanczyk
- Hospital de Clínicas de Porto AlegrePorto AlegreRSBrasilHospital de Clínicas de Porto Alegre, Porto Alegre, RS – Brasil
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Multivessel Versus Culprit-Only Revascularization in STEMI and Multivessel Coronary Artery Disease. JACC Cardiovasc Interv 2020; 13:1571-1582. [DOI: 10.1016/j.jcin.2020.04.055] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 11/21/2022]
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Kim YH, Her AY, Jeong MH, Kim BK, Hong SJ, Kim S, Ahn CM, Kim JS, Ko YG, Choi D, Hong MK, Jang Y. Culprit-only versus multivessel or complete versus incomplete revascularization in patients with non-ST-segment elevation myocardial infarction and multivessel disease who underwent successful percutaneous coronary intervention using newer-generation drug-eluting stents. Atherosclerosis 2020; 301:54-64. [PMID: 32330691 DOI: 10.1016/j.atherosclerosis.2020.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/26/2020] [Accepted: 04/01/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND AIMS The long-term comparative results between culprit-only percutaneous coronary intervention (C-PCI) and multivessel PCI (M-PCI) or those between complete revascularization (CR) and incomplete revascularization (IR) in patients with non-ST-elevation myocardial infarction (NSTEMI) and multivessel disease (MVD) after successful newer-generation drug-eluting stent (DES) implantation are limited. Therefore, we compared the 2-year clinical outcomes in such patients. METHODS A total of 4588 patients with NSTEMI and MVD (C-PCI, n = 2055; M-PCI, n = 2533; CR, n = 2029; IR, n = 504) were evaluated. The primary outcome was major adverse cardiac events (MACEs) defined as all-cause death, recurrent myocardial infarction MI, and any repeat coronary revascularization. The secondary outcome was stent thrombosis (ST). RESULTS The cumulative incidences of the primary and secondary outcomes were similar in the three comparison groups (C-PCI vs. M-PCI, CR vs. IR, or CR vs. C-PCI). However, the cumulative incidence of non-target vessel revascularization (non-TVR) was higher in the C-PCI group than in the M-PCI group (adjusted hazard ratio [aHR]: 2.011; 95% confidence interval [CI]: 1.942-3.985; p = 0.012), higher in the IR group than in the CR group (aHR: 2.051; 95% CI: 1.216-4.183; p = 0.043), and higher in the C-PCI group than in the CR group (aHR: 2.099; 95% CI: 1.237-3.564; p = 0.006). CONCLUSIONS Regarding the higher cumulative incidence of non-TVR, M-PCI and CR were preferred compared to C-PCI or IR in patients with NSTEMI and MVD. However, further randomized studies are required to confirm these findings.
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Affiliation(s)
- Yong Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Republic of Korea.
| | - Ae-Young Her
- Division of Cardiology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Republic of Korea
| | - Myung Ho Jeong
- Department of Cardiology, Cardiovascular Center, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Byeong-Keuk Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Sung-Jin Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Seunghwan Kim
- Division of Cardiology, Inje University College of Medicine, Haeundae Paik Hospital, Busan, Republic of Korea
| | - Chul-Min Ahn
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Jung-Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Young-Guk Ko
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Donghoon Choi
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Myeong-Ki Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Yangsoo Jang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
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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: 91] [Impact Index Per Article: 18.2] [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.
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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
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Nguyen AV, Thanh LV, Kamel MG, Abdelrahman SAM, EL-Mekawy M, Mokhtar MA, Ali AA, Hoang NNN, Vuong NL, Abd-Elhay FAE, Omer OA, Mohamed AA, Hirayama K, Huy NT. Optimal percutaneous coronary intervention in patients with ST-elevation myocardial infarction and multivessel disease: An updated, large-scale systematic review and meta-analysis. Int J Cardiol 2017. [DOI: 10.1016/j.ijcard.2017.06.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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.
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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.
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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]
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9
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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.
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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
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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.
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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
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Soeiro ADM, Scanavini Filho MA, Bossa AS, Zullino CN, Soeiro MCFA, Leal TCAT, Serrano Jr CV, Hajjar LA, Kalil Filho R, Oliveira Jr MT. Complete Treatment Versus Residual Lesion - Long-Term Evolution After Acute Coronary Syndrome. Arq Bras Cardiol 2016; 107:550-556. [PMID: 28558085 PMCID: PMC5210459 DOI: 10.5935/abc.20160176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 06/17/2016] [Accepted: 06/22/2016] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION A recently published study raised doubts about the need for percutaneous treatment of nonculprit lesions in patients with acute coronary syndromes (ACS). METHODS Retrospective, unicentric, observational study. OBJECTIVE To analyze the long-term outcomes in patients undergoing treatment of the culprit artery, comparing those who remained with significant residual lesions in nonculprit arteries (group I) versus those without residual lesions in other coronary artery beds (group II). The study included 580 patients (284 in group I and 296 in group II) between May 2010 and May 2013. We obtained demographic and clinical data, as well as information regarding the coronary treatment administered to the patients. In the statistical analysis, the primary outcome included combined events (reinfarction/angina, death, heart failure, and need for reintervention). The comparison between groups was performed using the chi-square test and ANOVA. The long-term analysis was conducted with the Kaplan-Meier method, with a mean follow-up of 9.86 months. RESULTS The mean ages were 63 years in group I and 62 years in group II. On long-term follow-up, there was no significant difference in combined events in groups I and II (31.9% versus 35.6%, respectively, p = 0.76). CONCLUSION The strategy of treating the culprit artery alone seems safe. In this study, no long-term differences in combined endpoints were observed between patients who remained with significant lesions compared with those without other obstructions.
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Affiliation(s)
- Alexandre de Matos Soeiro
- Unidade Clínica de Emergência - Instituto do
Coração (InCor) do Hospital das Clínicas da Universidade de
São Paulo, SP - Brazil
| | - Marco Antônio Scanavini Filho
- Unidade Clínica de Emergência - Instituto do
Coração (InCor) do Hospital das Clínicas da Universidade de
São Paulo, SP - Brazil
| | - Aline Siqueira Bossa
- Unidade Clínica de Emergência - Instituto do
Coração (InCor) do Hospital das Clínicas da Universidade de
São Paulo, SP - Brazil
| | - Cindel Nogueira Zullino
- Unidade Clínica de Emergência - Instituto do
Coração (InCor) do Hospital das Clínicas da Universidade de
São Paulo, SP - Brazil
| | | | | | - Carlos Vicente Serrano Jr
- Unidade Clínica de Emergência - Instituto do
Coração (InCor) do Hospital das Clínicas da Universidade de
São Paulo, SP - Brazil
| | - Ludhmila Abrahão Hajjar
- Unidade Clínica de Emergência - Instituto do
Coração (InCor) do Hospital das Clínicas da Universidade de
São Paulo, SP - Brazil
| | - Roberto Kalil Filho
- Unidade Clínica de Emergência - Instituto do
Coração (InCor) do Hospital das Clínicas da Universidade de
São Paulo, SP - Brazil
| | - Múcio Tavares Oliveira Jr
- Unidade Clínica de Emergência - Instituto do
Coração (InCor) do Hospital das Clínicas da Universidade de
São Paulo, SP - Brazil
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Management of non-ST-elevation myocardial infarction: A constant challenge. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.repce.2016.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Cyrne Carvalho H. Management of non-ST-elevation myocardial infarction: A constant challenge. Rev Port Cardiol 2016; 35:655-657. [PMID: 27863832 DOI: 10.1016/j.repc.2016.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Henrique Cyrne Carvalho
- Serviço de Cardiologia, Centro Hospitalar e Universitário do Porto, Hospital de Santo António, Porto, Portugal; Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal.
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Ahmad Y, Cook C, Shun-Shin M, Balu A, Keene D, Nijjer S, Petraco R, Baker CS, Malik IS, Bellamy MF, Sethi A, Mikhail GW, Al-Bustami M, Khan M, Kaprielian R, Foale RA, Mayet J, Davies JE, Francis DP, Sen S. Resolving the paradox of randomised controlled trials and observational studies comparing multi-vessel angioplasty and culprit only angioplasty at the time of STEMI. Int J Cardiol 2016; 222:1-8. [DOI: 10.1016/j.ijcard.2016.06.106] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 06/06/2016] [Accepted: 06/21/2016] [Indexed: 01/09/2023]
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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]
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Managing Multivessel Coronary Artery Disease in Patients With ST-Elevation Myocardial Infarction: A Comprehensive Review. Cardiol Rev 2016; 25:179-188. [PMID: 27124268 DOI: 10.1097/crd.0000000000000110] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Multivessel coronary artery disease (CAD) is found in up to 60% of the patients presenting with an ST-elevation myocardial infarction (STEMI) and worsens the prognosis proportional to the extent of CAD severity. However, the 2013 American College of Cardiology/American Heart Association STEMI guidelines, based on mostly observational data, had recommended against a routine noninfarct-related artery percutaneous coronary intervention (PCI). After these guidelines were published, a handful of randomized trials became available, and they suggested that PCI of significant lesions in a noninfarct-related artery at the time of primary PCI might result in improved patient outcomes. The incidence of major adverse cardiac events was significantly reduced by 55% at 1 year and 65% at 2 years in patients undergoing angiographically guided PCI of nonculprit vessels at the time of primary PCI, in 2 different randomized trials. Fractional flow reserve-guided PCI of nonculprit vessels in this setting has also been shown to reduce cardiac events by 44% at 1 year. Meta-analyses of both nonrandomized and randomized trials have also suggested that complete revascularization at the time of STEMI significantly improves outcomes, including long-term all-cause mortality. In view of the emerging data, a focused update on primary PCI was published in 2015 and suggested that PCI of noninfarct-related arteries might be considered in selected patients. This article is a comprehensive review of the literature on the treatment of multivessel CAD in patients with STEMI, which provides the reader a critical analysis of the available information to determine the best therapeutic approach.
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Spencer FA, Sekercioglu N, Prasad M, Lopes LC, Guyatt GH. Culprit vessel versus immediate complete revascularization in patients with ST-segment myocardial infarction-a systematic review. Am Heart J 2015; 170:1133-9. [PMID: 26678635 DOI: 10.1016/j.ahj.2015.09.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 09/01/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Guidelines suggest percutaneous intervention (PCI) of only the culprit artery in patients presenting with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease. However, recent randomized controlled trials (RCTs) suggest benefit to performing PCI of other stenotic vessels at the same time as culprit vessel PCI. METHODS We conducted a systematic review with complete case meta-analysis and sensitivity analyses. Data sources included MEDLINE, EMBASE, Cochrane Register of Controlled Trials, and CINAHL from 1946 to March 2014; MEDLINE and EMBASE from March 2014 to March 2015; and scanning of literature for new studies until August 2015. All RCTs comparing multivessel versus culprit-only PCI in patients with STEMI were eligible. The primary outcomes of interest were recurrent myocardial infarction (MI), recurrent revascularization, and mortality. We combined data from trials to estimate the pooled risk ratio (RR) and associated 95% CIs using random-effects models. RESULTS Five RCTs including 1,606 patients of whom 1,568 had complete data proved eligible. Multivessel revascularization was associated with decreased risk of repeat revascularization (RR 0.36, 95% CI 0.27-0.49, risk difference 9.7% over 2 years) and recurrent nonfatal MI (RR 0.58, 95% CI 0.36-0.93, risk difference 1.8% over 2 years), without increase in mortality (RR 0.82, 95% CI 0.53-1.26) or other adverse events. CONCLUSIONS Pooled data provide moderate-certainty evidence that performance of multivessel PCI will provide an appreciable reduction in nonfatal MI and high-certainty evidence that it will reduce need for repeat revascularization. Patients are likely to place a high value on these benefits.
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Affiliation(s)
| | - Nigar Sekercioglu
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Manya Prasad
- Department of Community Medicine, Pt. B. D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
| | | | - Gordon H Guyatt
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
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Ruggieri A, Piraino D, Dendramis G, Cortese B, Carella M, Buccheri D, Andolina G, Assennato P. STEMI patients and nonculprit lesions: To treat or not to treat? and when? A review of most recent literature. Catheter Cardiovasc Interv 2015; 87:1258-68. [DOI: 10.1002/ccd.26236] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 08/24/2015] [Indexed: 11/06/2022]
Affiliation(s)
- Aldo Ruggieri
- Section of Interventional Cardiology and Haemodynamics; A.O.U.P “Paolo Giaccone”; Palermo Italy
| | - Davide Piraino
- Section of Interventional Cardiology and Haemodynamics; A.O.U.P “Paolo Giaccone”; Palermo Italy
- Interventional Cardiology, A.O. Fatebenefratelli, Milan; Italy
| | - Gregory Dendramis
- Section of Interventional Cardiology and Haemodynamics; A.O.U.P “Paolo Giaccone”; Palermo Italy
- Section of Intensive Coronary Care Unit, A.O.U.P “Paolo Giaccone”; Palermo Italy
| | | | - Michele Carella
- Section of Interventional Cardiology and Haemodynamics; A.O.U.P “Paolo Giaccone”; Palermo Italy
| | - Dario Buccheri
- Section of Interventional Cardiology and Haemodynamics; A.O.U.P “Paolo Giaccone”; Palermo Italy
- Interventional Cardiology, A.O. Fatebenefratelli, Milan; Italy
| | - Giuseppe Andolina
- Section of Interventional Cardiology and Haemodynamics; A.O.U.P “Paolo Giaccone”; Palermo Italy
| | - Pasquale Assennato
- Section of Intensive Coronary Care Unit, A.O.U.P “Paolo Giaccone”; Palermo Italy
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Complete versus culprit-only revascularization in patients with multi-vessel disease undergoing primary percutaneous coronary intervention: A meta-analysis of randomized trials. Int J Cardiol 2015; 186:98-103. [PMID: 25814353 DOI: 10.1016/j.ijcard.2015.03.163] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Revised: 02/12/2015] [Accepted: 03/15/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND The best approach for revascularization of multi-vessel coronary disease in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) is controversial. METHODS We searched the Medline and Web of Science databases, the Cochrane Register of Controlled Trials, and major conference proceedings for clinical trials that randomized STEMI patients with multi-vessel disease to a complete versus culprit-only revascularization strategy. Random effects summary risk ratios (RR) were constructed using a DerSimonian-Laird model. RESULTS A total of 6 trials met our selection criteria, which yielded 1,190 patients. The mean follow-up duration was 20.5 months. The incidence of major adverse cardiac events was significantly reduced in the complete revascularization group versus the culprit-only revascularization group (RR 0.57, 95% confidence interval (CI) 0.41-0.78, p < 0.001). This was due to a lower risk of urgent revascularization with complete revascularization (RR 0.55, 95% CI 0.35-0.86, p = 0.01). A non-significant reduction was observed with complete versus culprit-only revascularization for the combined outcome of mortality or myocardial infarction (RR 0.56, 95% CI 0.30-1.04, p = 0.06). CONCLUSION Complete revascularization of significant coronary lesions at the time of primary PCI in patients with STEMI and multi-vessel disease was associated with better outcomes. This was primarily due to a reduction in the need for urgent revascularization. Larger trials are needed to determine if complete revascularization reduces death or myocardial infarction.
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