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Lin SM, Chang CH, Lin TY, Huang ACC, Lin CH, Chen YC, Chu PH. Plasma thrombomodulin levels are associated with acute kidney injury in patients with acute heart failure. Ann Med 2022; 54:3169-3176. [PMID: 36354140 PMCID: PMC9704091 DOI: 10.1080/07853890.2022.2142660] [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: 11/11/2022] Open
Abstract
Cardiorenal syndrome type I (CRS I) is defined as the development of acute kidney injury (AKI) following acute decompensated heart failure (ADHF). The clinical significance of endothelial markers in ADHF-associated AKI has yet to be clarified. This study therefore investigated the biological processes linking ADHF and AKI with the aim of determining whether the plasma markers of endothelial injury and activation are associated with AKI in patients with ADHF. The study prospectively recruited 125 consecutive patients admitted to a coronary critical unit due to ADHF. Patients with and without AKI were compared in terms of soluble thrombomodulin (sTM), angiopoietin (Ang)-1 and -2 plasma levels as well as baseline characteristics. Among the study population, 14 (11.2%) patients developed CRS within 7 days after admission. The hemoglobin levels (median [IQR]11.3[10.8-12.6] vs. 13.5 [12.2-15.0] g/dL, p = 0.003) and baseline eGFR (66.5[35.7-87.9] vs. 78.5 [64.9-107.5] mL/minute/1.73m2, p = 0.044) of patients with CRS were lower than those of patients without CRS. Patients with CRS also presented elevated plasma levels of BNP (1317.5 [222.6-3375.5] vs. 258.2 [63.2-925.8] pg/mL, p = 0.008), Ang-2 (3993.0 [1561.3-15722.7] vs. 1805.9 [1196.9-3302.3] pg/mL, p = 0.006), and sTM (6665.7 [4707.1-11947.3] vs. 4132.2 [3338.0-5531.8] ng/mL, p < 0.001), compared to patients without CRS. Multivariate logistic regression analysis based on forward stepwise method identified that log sTM was the only independent risk factor for AKI (OR, 13.83; 3.02-63.28, p = 0.001). Furthermore, higher sTM levels were associated with AKI in patients with ADHF. These findings suggest a novel approach to dealing with kidney injury in the context of ADHF, involving the use of baseline biomarker profiles to identify individuals at risk of developing AKI.KEY MESSAGESThe clinical significance of endothelial markers in acute decompensated heart failure (ADHF)-associated acute kidney injury (AKI) has not previously been clarified. This study revealed that markers of endothelial injury (i.e. plasma soluble thrombomodulin (sTM) levels) were higher in ADHF patients with AKI than in those without AKI.Multivariate analysis identified sTM level > cutoff value of 4,855.2 pg/mL as an independent factor associated with the development of AKI. sTM could potentially be used as a biomarker to predict the development of AKI in patients with heart failure.These findings suggest a novel approach to dealing with kidney injury in the context of ADHF, involving the use of baseline biomarker profiles to identify individuals at risk of developing AKI.
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Affiliation(s)
- Shu-Min Lin
- Department of Thoracic Medicine, School of Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan.,Department of Respiratory Therapy, School of Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Chih-Hsiang Chang
- Department of Nephrology, School of Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Ting-Yu Lin
- Department of Thoracic Medicine, School of Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Allen Chung-Cheng Huang
- Department of Thoracic Medicine, School of Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Chiung-Hung Lin
- Department of Thoracic Medicine, School of Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Yung-Chang Chen
- Department of Nephrology, School of Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Pao-Hsien Chu
- Department of Cardiology, School of Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
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2
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Kong E. Can C-11 Acetate PET Be a Feasible Option for Assessing Non-Culprit Lesion in STEMI Patients? J Cardiovasc Imaging 2022; 30:181-184. [PMID: 35879253 PMCID: PMC9314230 DOI: 10.4250/jcvi.2022.0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/23/2022] [Accepted: 04/26/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Eunjung Kong
- Department of Nuclear Medicine, Yeungnam University Medical School and Hospital, Daegu, Korea
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3
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Brunet T, Bonello L, Chamandi C, Tea V, Nallet O, Lhermusier T, Gallet R, Labèque JN, Albert F, Schiele F, Ferrières J, Simon T, Danchin N, Puymirat E. Long-term mortality after ST-elevation myocardial infarction in the reperfusion and modern secondary prevention therapy era according to coronary artery disease extent: The FAST-MI registries. Arch Cardiovasc Dis 2021; 114:647-655. [PMID: 34772646 DOI: 10.1016/j.acvd.2021.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/01/2021] [Accepted: 06/14/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Historical cohorts have shown extent of coronary artery disease to be a predictor of poorer outcomes in ST-segment elevation myocardial infarction. However, contemporary data in the era of reperfusion and modern secondary prevention therapy are lacking. AIM To compare 3-year survival in patients with ST-segment elevation myocardial infarction with multivessel disease versus those with single-vessel disease. METHODS Using data from the FAST-MI 2005, 2010 and 2015 registries, three nationwide French surveys, we included all patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention within 24hours of symptom onset. Baseline characteristics, management and 3-year all-cause mortality were analysed according to coronary status (single-, two- and three-vessel disease). RESULTS Among 3907 patients (mean age 62.4±13.7 years; 75.9% male), patients with multivessel disease (two- or three-vessel disease) accounted for 47.9%; overall, they were older, with higher cardiovascular risk profiles. In a multivariable adjusted Cox proportional hazard regression model, only patients with three-vessel disease had a higher rate of mortality at 3 years compared with those with single-vessel disease (hazard ratio 1.52, 95% confidence interval 1.68-2.26; P<0.001). Finally, patients with multivessel disease with complete myocardial revascularization before discharge had a similar prognosis to patients with single-vessel disease (hazard ratio 1.17, 95% confidence interval 0.84-1.64; P=0.35). CONCLUSIONS Multivessel disease still represents an important proportion of patients with ST-segment elevation myocardial infarction. Although three-vessel disease is associated with higher 3-year mortality, patients with multivessel disease and complete myocardial revascularization in the contemporary era have a 3-year risk of death similar to that in patients with single-vessel disease.
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Affiliation(s)
- Thibaud Brunet
- Department of Cardiology, hôpital Européen Georges-Pompidou, AP-HP, 75015 Paris, France; Université de Paris, 75006 Paris, France
| | - Laurent Bonello
- Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), Centre for Cardiovascular and Nutrition Research, AP-HM, Aix-Marseille University, Inserm 1263, INRA 1260 Cardiology Department, hôpital Nord, 13015 Marseille, France
| | - Chekrallah Chamandi
- Department of Cardiology, hôpital Européen Georges-Pompidou, AP-HP, 75015 Paris, France; Université de Paris, 75006 Paris, France
| | - Victoria Tea
- Department of Cardiology, hôpital Européen Georges-Pompidou, AP-HP, 75015 Paris, France; Université de Paris, 75006 Paris, France
| | - Olivier Nallet
- Department of Cardiology, Le Raincy-Montfermeil Intercity Hospital, 93370 Montfermeil, France
| | - Thibault Lhermusier
- Intensive Cardiac Care Unit, Department of Cardiology, Rangueil University Hospital, Medical School, Toulouse III Paul-Sabatier University, 31059 Toulouse, France
| | - Romain Gallet
- Service de Cardiologie, Hôpitaux Universitaires Henri-Mondor, AP-HP, 94000 Créteil, France; U955-IMRB, Equipe 03, Inserm, université Paris Est Creteil (UPEC), ecole nationale vétérinaire D'Alfort (EnVA), 94700 Maisons-Alfort, France
| | - Jean-Noel Labèque
- GCS de Cardiologie de la Côte Basque, CH Bayonne, 64100 Bayonne, France
| | - Franck Albert
- Department of Cardiology, Centre Hospitalier de Chartres, 28630 Le Coudray, France
| | - François Schiele
- Department of Cardiology, University Hospital Jean-Minjoz, 25000 Besançon, France
| | - Jean Ferrières
- Department of Cardiology, Rangueil Hospital, 31059 Toulouse, France
| | - Tabassome Simon
- Department of Clinical Pharmacology and unité de recherche clinique (URCEST), hôpital Saint-Antoine, AP-HP, 75012 Paris, France; Université Pierre et Marie Curie (UPMC-Paris 06), 75005 Paris, France
| | - Nicolas Danchin
- Department of Cardiology, hôpital Européen Georges-Pompidou, AP-HP, 75015 Paris, France; Université de Paris, 75006 Paris, France
| | - Etienne Puymirat
- Department of Cardiology, hôpital Européen Georges-Pompidou, AP-HP, 75015 Paris, France; Université de Paris, 75006 Paris, France.
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4
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Hu MJ, Yang YJ, Yang JG. Immediate Versus Staged Multivessel PCI Strategies in Patients with ST-Segment Elevation Myocardial Infarction and Multivessel Disease: A Systematic Review and Meta-analysis. Am J Med Sci 2021; 363:161-173. [PMID: 34274323 DOI: 10.1016/j.amjms.2021.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 02/22/2021] [Accepted: 06/02/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recent guidelines and randomized clinical trials favor the multivessel percutaneous coronary intervention (MV-PCI) strategy undertaken immediately or staged after primary PCI in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease. However, the optimal strategy of MV-PCI remains unknown. METHODS We conducted a search of PUBMED, EMBASE, Web of Science, the Cochrane database (CENTRAL), clinicaltrial.gov, and Google Scholar for studies comparing immediate versus staged MV-PCI in patients with STEMI and multivessel disease. Pooled odds ratios (OR) and 95% confidence intervals (CI) were estimated using random-effects models. RESULTS Eighteen (4 randomized clinical trials) studies with 8,100 patients fulfilled the inclusion criteria. Relative to staged MV-PCI, immediate MV-PCI was associated with higher short-term (within 30 days) (OR, 3.96; 95% CI, 2.07-7.59; P<0.0001) and long-term (above 6 months) mortality (OR, 2.12; 95% CI, 1.46-3.07; P<0.0001), short-term major adverse cardiovascular events (MACE)(OR, 1.99; 95% CI, 1.13-3.50; P=0.02) and cardiac death (OR, 4.78; 95% CI, 2.17-10.53; P=0.0001). There was a nonsignificant trend towards higher long-term MACE (OR, 1.23; 95% CI, 0.98-1.54; P=0.07) and cardiac death (OR, 1.75; 95% CI, 0.93-3.30; P=0.08) with immediate versus staged MV-PCI. Revascularization, myocardial infarction, and safety endpoints including stroke, major bleeding, and renal failure were similar between immediate versus staged MV-PCI. However, pooled analysis of randomized clinical trials did not show any significant differences in long-term MACE, all-cause mortality, myocardial infarction, and revascularization. CONCLUSIONS Our meta-analysis suggests that among patients with STEMI and multivessel disease, staged instead of immediate MV-PCI may be the optimal revascularization strategy.
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Affiliation(s)
- Meng-Jin Hu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Yue-Jin Yang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Jin-Gang Yang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China.
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5
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Hu MJ, Li XS, Jin C, Yang YJ. Does multivessel revascularization fit all patients with STEMI and multivessel coronary artery disease? A systematic review and meta-analysis. IJC HEART & VASCULATURE 2021; 35:100813. [PMID: 34169144 PMCID: PMC8209177 DOI: 10.1016/j.ijcha.2021.100813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/06/2021] [Accepted: 05/31/2021] [Indexed: 11/04/2022]
Abstract
Objective We sought to assess the relative merits of different revascularization strategies in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease complicated by cardiogenic shock or chronic total occlusion (CTO). Background Recent randomized trials and meta-analysis have suggested that multivessel percutaneous coronary intervention (PCI) is associated with better outcomes in patients with STEMI and multivessel coronary artery disease, however, patients complicated by cardiogenic shock or CTO were excluded. Methods Studies that compared multivessel PCI (immediate or staged) with culprit-only PCI in patients with STEMI and multivessel coronary artery disease complicated by cardiogenic shock or CTO were included. Random odd ratio (OR) and 95% confidence interval (CI) were conducted. Results Sixteen studies with 8695 patients complicated by cardiogenic shock and eight studies with 2259 patients complicated by CTO were included. In patients complicated by cardiogenic shock, a strategy of CO-PCI was associated with lower risk for short-term renal failure (OR: 0.75; 95% CI: 0.61–0.93; I2 = 0.0%), with no significant difference in MACE, all-cause mortality, re-infarction, revascularization, cardiac death, heart failure, major bleeding, or stroke compared with an immediate MV-PCI strategy. In patients complicated by CTO, a strategy of CO-PCI was associated with higher risk for long-term MACE (OR: 2.06; 95% CI: 1.39–3.06; I2 = 54.0%), all-cause mortality (OR: 2.89; 95% CI: 2.09–4.00; I2 = 0.0%), cardiac death (OR: 3.12; 95% CI: 2.05–4.75; I2 = 16.8%), heart failure (OR: 1.99; 95% CI: 1.22–3.24; I2 = 0.0%), and stroke (OR: 2.80; 95% CI: 1.04–7.53; I2 = 0.0%) compared with a staged MV-PCI strategy, without any difference in re-infarction, revascularization, or major bleeding. Conclusions For patients with STEMI and multivessel coronary artery disease complicated by cardiogenic shock, an immediate multivessel PCI was not advocated due to a higher risk for short-term renal failure, whereas for patients complicated by CTO, a staged multivessel PCI was advocated due to reduced risks for long-term MACE, all-cause mortality, cardiac death, heart failure, and stroke.
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Affiliation(s)
- Meng-Jin Hu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Xiao-Song Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Chen Jin
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Yue-Jin Yang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
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6
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Liu ES, Hung CC, Chiang CH, Chang CH, Cheng CC, Kuo FY, Mar GY, Huang WC. Comparison of Different Timing of Multivessel Intervention During Index-Hospitalization for Patients With Acute Myocardial Infarction. Front Cardiovasc Med 2021; 8:639750. [PMID: 34179128 PMCID: PMC8222548 DOI: 10.3389/fcvm.2021.639750] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/29/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Many patients presenting with acute myocardial infarction (AMI) were found to have a multivessel disease. Uncertainty still exists in the optimal revascularization strategy in AMI patients. The purpose of this study was to assess the outcome of immediate multivessel revascularization compared with staged multivessel percutaneous coronary intervention (PCI) in patients with AMI. Method: This was a nationwide cohort study of 186,112 patients first diagnosed with AMI, 78,699 of whom received PCI for revascularization. Patients who received repetitive PCI during the index hospitalization were referred to as staged multivessel PCI. Immediate multivessel PCI was defined as patients with two-vessel PCI or three-vessel PCI during the index procedure. Cox proportional hazards regression models were performed to evaluate the different indicators of mortality risks in AMI. Result: Immediate multivessel PCI was associated with a worse long-term outcome than staged multivessel PCI during the index admission (log-rank P < 0.001). There was a higher incidence of stroke in patients with multivessel PCI during hospitalization. In Cox analysis, immediate multivessel PCI was an independent risk factor for mortality compared to those with staged multivessel PCI, regardless of the type of myocardial infarction. Conclusion: This study demonstrated that performing immediate multivessel PCI for AMI may lead to worse long-term survival than staged multivessel PCI. Our findings emphasized the importance of PCI timing for non-infarct-related artery stenosis and provided information to supplement current evidence.
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Affiliation(s)
- En-Shao Liu
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Cheng Chung Hung
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Cheng-Hung Chiang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan
| | - Chia-His Chang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chin-Chang Cheng
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Feng-You Kuo
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Guang-Yuan Mar
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan.,Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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7
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Puymirat E, Nakache A, Saint Etienne C, Marcollet P, Fichaux O, Decomis MP, Chassaing S, Commeau P, Danchin N, Cayla G, Montalescot G, Benamer H, Koning R, Motreff P, Rangé G. Is coronary multivessel disease in acute myocardial infarction patients still associated with worse clinical outcomes at 1-year? Clin Cardiol 2021; 44:429-437. [PMID: 33586188 PMCID: PMC7943894 DOI: 10.1002/clc.23567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/30/2020] [Accepted: 01/07/2021] [Indexed: 11/23/2022] Open
Abstract
Background ST‐elevation myocardial infarction (STEMI) patients with multivessel disease (MVD) are associated with a worse prognosis. However, few comparisons are available according to coronary status in the era of modern reperfusion and optimized secondary prevention. Hypothesis We hypothesized that the difference in prognosis according to number of vessel disease in STEMI patients has reduced. Methods All consecutive STEMI patients undergoing primary percutaneous coronary intervention (PCI) within 24 h of symptoms onset between January 1, 2014 and June 30, 2016 enrolled in the CRAC (Club Régional des Angioplasticiens de la région Centre) France PCI registry were analyzed. Baseline characteristics, management, and outcomes at 1‐year were analyzed according to coronary status (one‐, two‐, and three‐VD). Results A total of 1886 patients (mean age 62.2 ± 14.0 year; 74% of male) were included. Patients with MVD (two or three‐VD) represented 53.7%. They were older with higher cardiovascular risk factor profile. At 1 year, the rate of major adverse cardiovascular events (MACE, defined as all‐cause death, stroke or re‐MI) was 10%, 12%, and 12% in one‐, two, and three‐VD respectively (p = .28). In multivariable adjusted Cox proportional hazard regression model, two‐ and three‐VD were not associated with higher rate of MACE compared to patients with single VD (HR, 1.09; 95%CI 0.76–1.56 for two‐VD; HR, 0.74; 95%CI 0.48–1.14 for three‐VD). Conclusions MVD still represents an important proportion of STEMI patients but their prognoses were not associated with worse clinical outcomes at 1‐year compared with one‐VD patients in a modern reperfusion area and secondary medication prevention.
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Affiliation(s)
- Etienne Puymirat
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France.,Université de Paris, Paris, France
| | - Ariel Nakache
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France.,Université de Paris, Paris, France
| | | | - Pierre Marcollet
- Cardiology Department, Centre Hospitalier de Bourges, Bourges, France
| | - Olivier Fichaux
- Cardiology Department, Centre Hospitalo-régional d'Orléans, Orléans, France
| | | | | | - Philippe Commeau
- Cardiology Department, Polyclinique les Fleurs, Ollioules, France
| | - Nicolas Danchin
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France.,Université de Paris, Paris, France
| | - Guillaume Cayla
- Cardiology Department, CHU Nîmes, Université Montpellier, Nîmes, France
| | - Gilles Montalescot
- Cardiology Department, Groupe hospitalier Pitié-Salpêtrière, Paris, France
| | - Hakim Benamer
- Cardiology Department, Clinique de la Roseraie; ICPS Massy Ramsay group, Paris 13, France
| | - Rene Koning
- Cardiology Department, Clinique Saint-Hilaire, Rouen, France
| | - Pascal Motreff
- Cardiology Department, Centre Hospitalo-Universitaire de Clermont-Ferrand, Clermont Ferrand, France
| | - Grégoire Rangé
- Cardiology Department, Les Hôpitaux de Chartres, Chartres, France
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8
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Omer MA, Exaire JE, Jentzer JC, Sandoval YB, Singh M, Cagin CR, Elgendy IY, Tak T. Management of ST-Elevation Myocardial Infarction in High-Risk Settings. Int J Angiol 2021; 30:53-66. [PMID: 34025096 DOI: 10.1055/s-0041-1723941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Despite the widespread adoption of primary percutaneous intervention and modern antithrombotic therapy, ST-segment elevation myocardial infarction (STEMI) remains the leading cause of death in the United States and remains one of the most important causes of morbidity and mortality worldwide. Certain high-risk patients present a challenge for diagnosis and treatment. The widespread adoption of primary percutaneous intervention in addition to modern antithrombotic therapy has resulted in substantial improvement in the short- and long-term prognosis following STEMI. In this review, we aim to provide a brief analysis of the state-of-the-art treatment for patients presenting with STEMI, focusing on cardiogenic shock, current treatment and controversies, cardiac arrest, and diagnosis and treatment of mechanical complications, as well as multivessel and left main-related STEMI.
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Affiliation(s)
- Mohamed A Omer
- Cardiovascular Services, Mayo Clinic Health System, La Crosse, Wisconsin.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jose E Exaire
- Cardiovascular Services, Mayo Clinic Health System, La Crosse, Wisconsin.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Charles R Cagin
- Cardiovascular Services, Mayo Clinic Health System, La Crosse, Wisconsin.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Islam Y Elgendy
- Division of Cardiology, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Tahir Tak
- Cardiovascular Services, Mayo Clinic Health System, La Crosse, Wisconsin.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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9
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Yanase T, Sakakura K, Taniguchi Y, Yamamoto K, Tsukui T, Seguchi M, Wada H, Momomura SI, Fujita H. Comparison of Clinical Characteristics of Acute Myocardial Infarction Between Young (< 55 Years) and Older (55 to < 70 Years) Patients. Int Heart J 2021; 62:33-41. [PMID: 33518663 DOI: 10.1536/ihj.20-444] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Although the incidence of acute myocardial infarction (AMI) has been decreasing in the elderly, it has been increasing in the young, especially in Japan. A social impact of AMI would be greater in the young, because loss of the young directly influences social activities such as business, child-raising, and tax payment. The aim of this study was to identify the specific characteristics of young AMI patients. We retrospectively included 408 consecutive AMI patients < 70 years of age, divided into a young group (< 55 years: n = 136) and an older group (55 to < 70 years: n = 272). The prevalence of overweight was greater in the young group (58.5%) than in the older group (40.7%) (P = 0.001). The frequency of current smokers was higher in the young group (67.6%) than in the older group (44.9%) (P < 0.001). Although the prevalence of hypertension was lower in the young group (66.7%) than in the older group (77.2%) (P = 0.017), that of untreated hypertension was greater in the young group (40.4%) than in the older group (27.2%) (P = 0.007). Furthermore, the prevalence of untreated dyslipidemia was greater in the young group (45.0%) than in the older group (26.6%) (P < 0.001). In conclusion, the young AMI patients had more modifiable risk factors such as obesity, smoking, untreated hypertension, and untreated dyslipidemia than the older patients. There is an unmet medical need for the prevention of AMI in the young generation.
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Affiliation(s)
- Tomonobu Yanase
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
| | - Kenichi Sakakura
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
| | - Yousuke Taniguchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
| | - Kei Yamamoto
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
| | - Takunori Tsukui
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
| | - Masaru Seguchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
| | - Hiroshi Wada
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
| | - Shin-Ichi Momomura
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
| | - Hideo Fujita
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
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Chang K, Ahn Y, Lim S, Yang JH, Lee KY, Choo EH, Kim HK, Nam CW, Kim W, Hwang JY, Rha SW, Kim HS, Cho MC, Jang Y, Jeong MH. 2021 Korean Society of Myocardial Infarction Expert Consensus Document on Revascularization for Acute Myocardial Infarction. Korean Circ J 2021; 51:289-307. [PMID: 33821579 PMCID: PMC8022023 DOI: 10.4070/kcj.2021.0043] [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: 02/03/2021] [Accepted: 03/03/2021] [Indexed: 01/30/2023] Open
Abstract
Acute myocardial infarction (AMI) is a fatal manifestation of ischemic heart disease and remains a major public health concern worldwide despite advances in its diagnosis and management. The characteristics of patients with AMI, as well as its disease patterns, have gradually changed over time in Korea, and the outcomes of revascularization have improved dramatically. Several characteristics associated with the revascularization of Korean patients differ from those of patients in other countries. The sophisticated state of AMI revascularization in Korea has led to the need for a Korean expert consensus. The Task Force on Expert Consensus Document of the Korean Society of Myocardial Infarction has comprehensively reviewed the outcomes of large clinical trials and current practical guidelines, as well as studies on Korean patients with AMI. Based on these comprehensive reviews, the members of the task force summarize the major guidelines and recent publications, and propose an expert consensus for revascularization in patients with AMI.
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Affiliation(s)
- Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Youngkeun Ahn
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Sungmin Lim
- Division of Cardiology, Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwan Yong Lee
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eun Ho Choo
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun Kuk Kim
- Department of Internal Medicine, Chosun University College of Medicine, Gwangju, Korea
| | - Chang Wook Nam
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Weon Kim
- Division of Cardiovascular, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University, Seoul, Korea
| | - Jin Yong Hwang
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Seung Woon Rha
- Divison of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Hyo Soo Kim
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Myeong Chan Cho
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Yangsoo Jang
- Divison of Cardiology, Department of Internal Medicine, Severance Hospital, Seoul, Korea
| | - Myung Ho Jeong
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea.
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Bajraktari G, Bytyçi I, Henein MY, Alfonso F, Ahmed A, Jashari H, Bhatt DL. Complete revascularization for patients with multivessel coronary artery disease and ST-segment elevation myocardial infarction after the COMPLETE trial: A meta-analysis of randomized controlled trials. INTERNATIONAL JOURNAL OF CARDIOLOGY. HEART & VASCULATURE 2020; 29:100549. [PMID: 32577495 PMCID: PMC7301199 DOI: 10.1016/j.ijcha.2020.100549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/07/2020] [Accepted: 05/26/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The recently published COMPLETE trial has demonstrated that patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD), who underwent successful percutaneous coronary intervention (PCI) of both culprit and non-culprit (vs. culprit-only) lesions had a reduced risk of major adverse cardiac events (MACE), but not of cardiovascular or total mortality. The aim of this meta-analysis was to assess the efficacy of complete revascularization on cardiovascular or total mortality reduction using available randomized controlled trials (RCTs) including the COMPLETE trial, in hemodynamically stable STEMI patients with MVD. METHODS PubMed, MEDLINE, Embase, Scopus, Google Scholar, CENTRAL and ClinicalTrials.gov databases search identified 10 RCTs of 7033 patients with STEMI and MVD which compared complete (n = 3420) vs. only culprit lesion (n = 3613) PCI for a median 27.7 months follow-up. Random effect risk ratios were used to estimate for efficacy and safety outcomes. RESULTS Complete revascularization reduced the risk of MACE (10.4% vs.16.6%; RR = 0.59, 95% CI: 0.47 to 0.74, p < 0.0001), CV mortality (2.87% vs. 3.72%; RR = 0.73, 95% CI: 0.56 to 0.95, p = 0.02), reinfarction (5.1% vs. 7.1%; RR = 0.67, 95% CI: 0.52 to 0.86, p = 0.002), urgent revascularization (7.92% vs.17.4%; RR = 0.47, 95% CI: 0.30 to 0.73, p < 0.001), and CV hospitalization (8.68% vs.11.4%; RR = 0.65, 95% CI: 0.44to 0.96, p = 0.03) compared with culprit only revascularization. All-cause mortality, stroke, major bleeding events, or contrast induced nephropathy were not affected by the revascularization strategy. CONCLUSION The findings of this meta-analysis suggest that in patients with STEMI and MVD, complete revascularization is superior to culprit-only PCI in reducing the risk of MACE outcomes, including cardiovascular mortality, without increasing the risk of adverse safety outcomes.
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Affiliation(s)
- Gani Bajraktari
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- Clinic of Cardiology, University Clinical Centre of Kosovo, Prishtina, Kosovo
- University of Prishtina, Prishtina, Kosovo
| | - Ibadete Bytyçi
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- Clinic of Cardiology, University Clinical Centre of Kosovo, Prishtina, Kosovo
| | - Michael Y Henein
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Fernando Alfonso
- Cardiac Department, La Princesa University Hospital, Institute of Health Research, IIS-IP, CIBER-CV University Autónoma of Madrid, Madrid, Spain
| | - Ali Ahmed
- Veterans Affairs Medical Center, George Washington University, and Georgetown University, Washington, DC, USA
| | - Haki Jashari
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
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Puymirat E, Simon T, de Bruyne B, Montalescot G, Steg G, Cayla G, Durand-Zaleski I, Blanchard D, Danchin N, Chatellier G. Rationale and design of the Flow Evaluation to Guide Revascularization in Multivessel ST-Elevation Myocardial Infarction (FLOWER-MI) trial. Am Heart J 2020; 222:1-7. [PMID: 32000067 DOI: 10.1016/j.ahj.2019.12.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 12/21/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND In ST-elevation myocardial infarction (STEMI) patients presenting with multivessel disease (MVD), recent studies have demonstrated the superiority of fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) for non-culprit lesions compared to culprit lesion treatment-only therapy. FFR- and angio-guided PCI have however never been compared in STEMI patients. TRIAL DESIGN FLOWER-MI is an open-label multicenter national randomized clinical trial. The aim is to investigate FFR-guided complete revascularization in comparison to angio-guided complete revascularization in STEMI patients with successful PCI of the culprit lesion and ≥50% stenosis in at least one additional non-culprit lesion requiring PCI. Eligible patients will be randomized after successful primary PCI in a 1:1 fashion to either FFR-guided or angio-guided complete revascularization during the index procedure or a staged procedure before discharge (≤5 days). Patients assigned to FFR guidance first have FFR measured in each non-culprit vessel and only undergo PCI if FFR is ≤0.80. The primary end point of the study is a composite of major adverse cardiac events, including all-cause death, non-fatal MI, and unplanned hospitalization leading to urgent revascularization at 1 year. Secondary end points will include the individual adverse events, cost-effectiveness, quality of life, and 30-day, 6-month, and 3-year outcomes. Based on estimated event rates, a sample size of 1170 patients is needed to show superiority of the FFR-guided revascularization with 80% power. CONCLUSION The aim of FLOWER-MI trial is to assess whether FFR-guided complete revascularization in the acute setting is superior angio-guided complete revascularization.
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Ogiso M, Yamaguchi J, Kawada-Watanabe E, Koyanagi R, Sekiguchi H, Sakamoto T, Iguchi N, Tanaka H, Okada H, Ota Y, Jujo K, Fujii S, Ogawa H, Hagiwara N. Effect of Aggressive Lipid-Lowering Therapy in Single-Vessel vs. Multivessel Coronary Artery Disease Patients With Acute Coronary Syndrome - Heart Institute of Japan-Proper Level of Lipid Lowering With Pitavastatin and Ezetimibe in Acute Coronary Syndrome (HIJ-PROPER) Substudy. Circ Rep 2020; 2:128-134. [PMID: 33693218 PMCID: PMC7929759 DOI: 10.1253/circrep.cr-19-0118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background:
The effects of aggressive lipid-lowering therapy according to the number of diseased coronary arteries in acute coronary syndrome (ACS) are still controversial. This study investigated the efficacy of this therapy in ACS patients with multivessel disease (MVD) and single-vessel disease (SVD). Methods and Results:
The subjects were derived from the HIJ-PROPER study, in which ACS patients with dyslipidemia were randomized to receive either pitavastatin+ezetimibe (targeting low-density lipoprotein cholesterol [LDL-C] <70 mg/dL) or pitavastatin monotherapy (targeting LDL-C <90 mg/dL). In this study, treatment efficacy was compared between patients with MVD and SVD. The primary endpoint was a composite of major advanced cardiovascular events (MACE; all-cause death, non-fatal myocardial infarction, non-fatal stroke, and ischemia-driven revascularization). We identified 1,702 eligible patients (MVD, n=869; SVD, n=833; mean age, 65.6 years; male, 75.6%; acute revascularization, 96.2%). MACE incidence was significantly higher in the MVD group than in the SVD group (43.7% vs. 25.9%, HR, 1.95; 95% CI: 1.65–2.31, P<0.001). In the SVD group, pitavastatin+ezetimibe had significantly fewer MACE than pitavastatin monotherapy (34.6% vs. 47.4%, HR, 0.72; 95% CI: 0.55–0.94, P=0.02). Conclusions:
The benefits of aggressive lipid-lowering therapy, with the addition of ezetimibe to statins, were enhanced in ACS patients with SVD, but not with MVD, in the early invasive strategy era.
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Affiliation(s)
- Masataka Ogiso
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University Tokyo Japan
| | - Junichi Yamaguchi
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University Tokyo Japan
| | - Erisa Kawada-Watanabe
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University Tokyo Japan
| | - Ryo Koyanagi
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University Tokyo Japan
| | - Haruki Sekiguchi
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University Tokyo Japan
| | - Tomohiro Sakamoto
- Division of Cardiology, Cardiovascular Center, Saisei-Kai Kumamoto Hospital Kumamoto Japan
| | - Nobuo Iguchi
- Department of Cardiology, Sakakibara Heart Institute Fuchu Japan
| | - Hiroyuki Tanaka
- Division of Cardiology, Tokyo Metropolitan Tama Medical Center Fuchu Japan
| | - Hisayuki Okada
- Department of Cardiology, Seirei Hamamatsu General Hospital Hamamatsu Japan
| | - Yoshimi Ota
- Department of Cardiology, Saisei-Kai Kurihashi Hospital Kuki Japan
| | - Kentaro Jujo
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University Tokyo Japan
| | - Shinya Fujii
- Department of Cardiology, Cardiovascular Center of Sendai Sendai Japan
| | - Hiroshi Ogawa
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University Tokyo Japan
| | - Nobuhisa Hagiwara
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University Tokyo Japan
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Culprit-Only or Complete Revascularization for ST-Elevation Myocardial Infarction in Patients with and Without Shock. Interv Cardiol Clin 2020; 8:225-234. [PMID: 30832944 DOI: 10.1016/j.iccl.2019.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
ST-elevation myocardial infarction (STEMI) patients with multivessel disease and without shock are a common clinical entity, but the best approach to nonculprit vessel lesions remains controversial. In contrast, STEMI patients with shock do not appear to benefit from primary multivessel percutaneous coronary interventions (PCIs) during the index procedure. The optimal treatment strategy in a given STEMI patient involves an individualized approach, incorporating clinical, hemodynamic, and angiographic/imaging parameters. Patients with STEMI and cardiogenic shock may benefit from therapies other than PCI, such as mechanical cardiovascular support.
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Comparison Between Beta-Blockers with Angiotensin-Converting Enzyme Inhibitors and Beta-Blockers with Angiotensin II Type I Receptor Blockers in ST-Segment Elevation Myocardial Infarction After Successful Percutaneous Coronary Intervention with Drug-Eluting Stents. Cardiovasc Drugs Ther 2019; 33:55-67. [DOI: 10.1007/s10557-018-6841-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Park SH, Choi BG, Rha SW, Kang TS. The multi-vessel and diffuse coronary spasm is a risk factor for persistent angina in patients received anti-angina medication. Medicine (Baltimore) 2018; 97:e13288. [PMID: 30461639 PMCID: PMC6392675 DOI: 10.1097/md.0000000000013288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Coronary artery spasm (CAS) is known to be a risk factor for cardiovascular events. However, there is limited data whether the multi-vessel and diffuse spasm (MVDS) is related to more adverse clinical outcomes compared to the Non-MVDS. The aim of this study is to evaluate the impact of the MVDS on clinical outcomes during a 3-year clinical follow-up period.A total 2797 patients underwent coronary angiography (CAG) with acetylcholine (ACH) provocation test from Nov 2004 to Oct 2010 were enrolled. It is a single-center, observational, prospective, all-comers registry designed to reflect the "real world" practic. The patients were divided into the 3 groups; the negative spasm (NS) group (n = 1188), the Non-MVDS group (n = 1081), and the MVDS group (n = 528). The incidence of major adverse cardiac events (MACE) and recurrent angina was evaluated up to 3 years. To minimize confounding factors, multivariable Cox-proportional hazards regression analysis was performed.In the 3-year clinical follow-up, the incidence of total death, myocardial infarction, de novo percutaneous coronary intervention (PCI), cerebrovascular accident and MACE were similar among the 3 groups. However, recurrent angina occurred more frequently in the MVDS group than in the NS group (hazard ratio [HR], 1.96; 95% confidence interval [CI], 1.27-3.02; P = .002). Recurrence angina between the MVDS group and the Non-MVDS group was not statistically significant (HR, 1.36; 95% CI, 0.91-2.03; P = .129).In this study, although the incidence of major adverse cardiovascular events were not different regardless of spasm type, the MVDS was associated with higher incidence of recurrent chest pain requiring repeat CAG during the 3-year follow-up period, suggesting more intensive optimal medical therapy with close clinical follow up would be necessary for this particular subset of patients.
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Affiliation(s)
- Sang-Ho Park
- Cardiology Department, Soonchunhyang University Cheonan Hospital, Cheonan
| | - Byoung Geol Choi
- Department of Medicine, Korea University Graduate School, Seoul
- Cardiovascular Center, Korea University Guro Hospital, Seoul
| | - Seung-Woon Rha
- Cardiovascular Center, Korea University Guro Hospital, Seoul
| | - Tae Soo Kang
- Cardiovascular Division, Department of Internal Medicine, Dankook University Hospital, Cheonan, Korea
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17
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Fan PC, Chang CH, Chen YC. Biomarkers for acute cardiorenal syndrome. Nephrology (Carlton) 2018; 23 Suppl 4:68-71. [DOI: 10.1111/nep.13473] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Pei-Chun Fan
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Linkou Medical Center; Chang Gung University College of Medicine; Taoyuan Taiwan
- Graduate Institute of Clinical Medical Sciences; Chang Gung University; Taoyuan Taiwan
| | - Chih-Hsiang Chang
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Linkou Medical Center; Chang Gung University College of Medicine; Taoyuan Taiwan
- Graduate Institute of Clinical Medical Sciences; Chang Gung University; Taoyuan Taiwan
| | - Yung-Chang Chen
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung Branch; Chang Gung University College of Medicine; Keelung Taiwan
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18
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Kalra S, Bhatt H, Kirtane AJ. Stenting in Primary Percutaneous Coronary Intervention for Acute ST-Segment Elevation Myocardial Infarction. Methodist Debakey Cardiovasc J 2018; 14:14-22. [PMID: 29623168 DOI: 10.14797/mdcj-14-1-14] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The treatment of ST-segment elevation myocardial infarction (STEMI) has advanced dramatically over the past 30 years since the introduction of reperfusion therapies, such that mechanical reperfusion with primary percutaneous coronary intervention is now the standard of care. With STEMI, as with other forms of acute coronary syndrome, stent deployment in culprit lesions is the dominant form of reperfusion in the developed world and is supported by contemporary guidelines. However, the precise timing of stenting and the extent to which both culprit and non-culprit lesions should be treated continue to be active areas of study. In this review, we revisit key data that support the use of mechanical reperfusion therapy in STEMI patients and explore the optimal timing for and extent of stent implantation in this complex patient group. We also review data surrounding the deleterious effects of untreated residual myocardial ischemia, the importance of complete revascularization, and the recent data exploring culprit-only versus multivessel stenting in the STEMI setting.
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Affiliation(s)
- Sanjog Kalra
- aEINSTEIN MEDICAL CENTER, PHILADELPHIA, PENNSYLVANIA
| | - Hemal Bhatt
- aEINSTEIN MEDICAL CENTER, PHILADELPHIA, PENNSYLVANIA
| | - Ajay J Kirtane
- bCOLUMBIA UNIVERSITY/IRVING MEDICAL CENTER, NEW YORK, NEW YORK
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19
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Meta-Analysis of Culprit-Only Versus Multivessel Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Disease. Am J Cardiol 2018; 121:529-536. [PMID: 29304995 DOI: 10.1016/j.amjcard.2017.11.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 11/09/2017] [Accepted: 11/13/2017] [Indexed: 01/10/2023]
Abstract
Recently, several randomized controlled trials (RCT) in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) have compared a strategy of routine multivessel percutaneous coronary intervention (PCI) performed either as a single procedure or as staged procedures to culprit-only PCI. All of these trials have been underpowered for clinical end points. We searched PubMed, Embase, and Cochrane Central Register of Controlled Trials for RCT comparing multivessel PCI with culprit-only PCI in patients with STEMI and MVD. The primary efficacy outcome was the composite rate of death or MI. Other efficacy outcomes included death, MI, and repeat revascularization. Safety outcomes were contrast-associated acute kidney injury, stroke, and major bleeding. Pairwise direct comparison and mixed-treatment comparison network meta-analyses were performed. Eleven trials that enrolled 3,150 patients with a total of 5,296 patient-years of follow-up were included. In direct comparison meta-analysis, single-procedure multivessel PCI was associated with a reduction in the risk of death or MI (rate ratio [RR] = 0.52; 95% confidence interval [CI] 0.37 to 0.73; p <0.001), due to less death (RR = 0.64; 95% CI 0.40 to 1.02; p = 0.06) and MI (RR = 0.42; 95% CI 0.25 to 0.69; p <0.0001) compared with culprit-only PCI. No heterogeneity (I2 = 0) was present between studies. In contrast, staged multivessel PCI did not significantly reduce death or MI compared with culprit-only PCI. Both multivessel PCI strategies reduced the risk of repeat revascularization without significant differences in safety outcomes. Results were consistent in the mixed-treatment comparison meta-analysis. In conclusion, the present meta-analysis suggests that single-procedure multivessel PCI may be the preferred strategy in patients with STEMI and MVD.
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Correia C, Galvão Braga C, Martins J, Arantes C, Abreu G, Quina C, Salgado A, Álvares Pereira M, Costa J, Marques J. Multivessel vs. culprit-only revascularization in patients with non-ST-elevation acute coronary syndromes and multivessel coronary disease. Rev Port Cardiol 2018; 37:143-154. [PMID: 29486987 DOI: 10.1016/j.repc.2017.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 04/09/2017] [Accepted: 05/03/2017] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION There have been no prospective randomized trials that enable the best strategy and timing to be determined for revascularization in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and multivessel coronary artery disease (CAD). OBJECTIVES To compare short- and long-term adverse events following multivessel vs. culprit-only revascularization in patients with NSTE-ACS and multivessel CAD. METHODS This was a retrospective observational study that included all patients diagnosed with NSTE-ACS and multivessel CAD who underwent percutaneous coronary intervention (PCI) between January 2010 and June 2013 (n=232). After exclusion of patients with previous coronary artery bypass grafting (n=30), a multivessel revascularization strategy was adopted in 35.1% of patients (n=71); in the others (n=131, 64.9%), only the culprit artery was revascularized. After propensity score matching (PSM), two groups of 66 patients were obtained, matched according to revascularization strategy. RESULTS During follow-up (1543±545 days), after PSM, patients undergoing multivessel revascularization had lower rates of reinfarction (4.5% vs. 16.7%; log-rank p=0.018), unplanned revascularization (6.1% vs. 16.7%; log-rank p=0.048), unplanned PCI (3.0% vs. 13.6%; log-rank p=0.023) and the combined endpoint of death, reinfarction and unplanned revascularization (16.7 vs. 31.8%; log-rank p=0.046). CONCLUSIONS In real-world patients presenting with NSTE-ACS and multivessel CAD, a multivessel revascularization strategy was associated with lower rates of reinfarction, unplanned revascularization and unplanned PCI, as well as a reduction in the combined endpoint of death, reinfarction and unplanned revascularization.
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Affiliation(s)
- César Correia
- Escola de Ciências da Saúde, Universidade do Minho, Braga, Portugal
| | | | | | - Carina Arantes
- Serviço de Cardiologia, Hospital de Braga, Braga, Portugal
| | - Glória Abreu
- Serviço de Cardiologia, Hospital de Braga, Braga, Portugal
| | - Catarina Quina
- Serviço de Cardiologia, Hospital de Braga, Braga, Portugal
| | | | | | - João Costa
- Serviço de Cardiologia, Hospital de Braga, Braga, Portugal
| | - Jorge Marques
- Serviço de Cardiologia, Hospital de Braga, Braga, Portugal
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21
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Correia C, Galvão Braga C, Martins J, Arantes C, Abreu G, Quina C, Salgado A, Álvares Pereira M, Costa J, Marques J. Multivessel vs. culprit-only revascularization in patients with non-ST-elevation acute coronary syndromes and multivessel coronary disease. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.repce.2017.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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22
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Routine angiographic follow-up versus clinical follow-up in patients with multivessel coronary artery diseases following percutaneous coronary intervention with drug-eluting stents: a nested case-control study within a Korean population. Coron Artery Dis 2018; 28:307-314. [PMID: 28272162 DOI: 10.1097/mca.0000000000000479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The difference in the usefulness of routine angiographic follow-up (RAF) and clinical follow-up (CF) after a percutaneous coronary intervention (PCI) in multivessel coronary artery disease (MVD) patients has not been well clarified as yet. PATIENTS AND METHODS A total of 642 consecutive MVD patients who underwent PCI with drug-eluting stents (DES) were enrolled. RAF was performed at 6-9 months after the index PCI (n=374) and others were medically managed and clinically followed (n=268). Patients who experienced clinical events including death, myocardial infarction (MI), and ischemia-driven PCI before 1 year were excluded. To adjust for any potential confounders, a propensity scorematched analysis was carried out using the logistic regression model and two propensity-matched groups (193 pairs, n=386, C-statistic=0.744) were generated. Cumulative clinical outcomes up to 3 years were compared between the RAF group and the CF group. RESULTS During the 3-year follow-up period, the cumulative incidence of revascularization [target lesion revascularization: odds ratio (OR), 4.21; 95% confidence interval (CI), 1.67-10.6; P=0.001) and target vessel revascularization (TVR: OR, 4.69; 95% CI, 2.00-11.0; P<0.001, target vessel revascularization: OR, 4.69; 95% CI, 2.00-1011.0; P<0.001] and major adverse cardiovascular events (composite of death, repeat PCI and MI: OR, 2.96; 95% CI, 1.62-105.42, P<0.001) were significantly higher in the RAF group compared with the CF group. However, the 3-year incidence of death (OR, 1.41; 95% CI, 0.44-104.53; P=0.558) or MI (OR, 2.58; 95% CI, 0.79-108.37; P=0.102) was not different between the two groups. In MVD patients treated with second-generation DESs, the incidence of repeat revascularization (target lesion revascularization and target vessel revascularization) was not different between the two groups. CONCLUSION Conclusion RAF following index PCI with DES in multivessel CAD patients was associated with increased incidence of revascularization and major adverse cardiovascular events. However, in MVD patients treated with second-generation DESs, repeat revascularization incidence was similar between two different follow-up strategies up to 3 years.
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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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Feistritzer HJ, Klug G, Reinstadler SJ, Reindl M, Niess L, Nalbach T, Kremser C, Mayr A, Metzler B. Prognostic Value of Aortic Stiffness in Patients After ST-Elevation Myocardial Infarction. J Am Heart Assoc 2017; 6:JAHA.117.005590. [PMID: 28887316 PMCID: PMC5634252 DOI: 10.1161/jaha.117.005590] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND High aortic stiffness has been shown to be a strong predictor of morbidity and mortality in the general population and several patient cohorts. However, in patients after ST-elevation myocardial infarction, the prognostic value of high aortic stiffness is unknown so far. METHODS AND RESULTS This prospective observational study included 160 consecutive patients with first acute ST-elevation myocardial infarction. Aortic pulse wave velocity (PWV) was measured 2 (interquartile range 2-4 days) days after infarction using cardiac magnetic resonance imaging. The primary end point was defined as a composite end point of major adverse cardiac and cerebrovascular events (MACCE) comprising death, nonfatal myocardial reinfarction, new congestive heart failure, and stroke. During a median follow-up of 1.2 years (interquartile range 1.0-3.1 years), 19 (12%) MACCE events occurred. Kaplan-Meier analysis showed a significantly lower MACCE-free survival in patients with high PWV (PWV >7.3 m/s, log-rank P=0.003). Multivariable Cox regression analysis revealed PWV >7.3 m/s to be an independent predictor of MACCE after adjustment for age, sex, mean blood pressure, N-terminal pro-brain natriuretic peptide levels, presence of multivessel disease, and left ventricular stroke volume (hazard ratios ≥3.5; 95% confidence interval 1.4-13.3; all P≤0.018). In reclassification analysis the addition of PWV to a risk model comprising major clinical prognostic parameters led to a net reclassification improvement of 0.11 (95% confidence interval 0.06-0.17; P<0.001). CONCLUSIONS Increased aortic stiffness is an independent predictor of MACCE after acute ST-elevation myocardial infarction. Moreover, the assessment of aortic stiffness in addition to classical risk factors significantly improved early risk stratification.
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Affiliation(s)
- Hans-Josef Feistritzer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Austria
| | - Sebastian J Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Austria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Austria
| | - Lea Niess
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Austria
| | - Timo Nalbach
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Austria
| | - Christian Kremser
- University Clinic of Radiology, Medical University of Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Austria
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Andries G, Khera S, Timmermans RJ, Aronow WS. Complete versus culprit only revascularization in ST-elevation myocardial infarction-a perspective on recent trials and recommendations. J Thorac Dis 2017; 9:2159-2167. [PMID: 28840017 DOI: 10.21037/jtd.2017.06.95] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The presence of multivessel coronary artery disease (CAD) is strongly associated with higher 30-day mortality, reduced myocardial reperfusion success, reinfarction, and occurrence of major adverse cardiac events (MACE) at 1 year compared with single-vessel CAD. Despite higher morbidity and mortality in patients with ST-elevation myocardial infarction (STEMI) and coexistent multivessel CAD, major guidelines recommended against percutaneous coronary intervention (PCI) on non-culprit lesions at the time of primary PCI in patients with STEMI who are hemodynamically stable. The presence of multivessel CAD often poses a therapeutic dilemma for interventional cardiologists. A few larger scale randomized controlled trials (RCTs) and meta-analyses have been conducted. The conclusions regarding multivessel PCI generally trend towards lower risk of MACE, repeat revascularization, with similar risks of recurrent myocardial infarction (MI) and mortality. However, none of the RCTs were adequately powered for hard outcomes of death and MI.
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Affiliation(s)
- Gabriela Andries
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Sahil Khera
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA.,Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Robert J Timmermans
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Wilbert S Aronow
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
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Quadri G, D’Ascenzo F, Moretti C, D’Amico M, Raposeiras-Roubín S, Abu-Assi E, Henriques JP, Saucedo J, González-Juanatey JR, Wilton S, Kikkert W, Nuñez-Gil I, Ariza-Sole A, Song X, Alexopoulos D, Liebetrau C, Kawaji T, Huczek Z, Nie SP, Fujii T, Correia L, Kawashiri MA, García-Acuña JM, Southern D, Alfonso E, Terol B, Garay A, Zhang D, Chen Y, Xanthopoulou I, Osman N, Möllmann H, Shiomi H, Omedè P, Montefusco A, Giordana F, Scarano S, Kowara M, Filipiak K, Wang X, Yan Y, Fan JY, Ikari Y, Nakahashi T, Sakata K, Yamagishi M, Kalpak O, Kedev S, Varbella F, Gaita F. Complete or incomplete coronary revascularisation in patients with myocardial infarction and multivessel disease: a propensity score analysis from the “real-life” BleeMACS (Bleeding complications in a Multicenter registry of patients discharged with diagnosis of Acute Coronary Syndrome) registry. EUROINTERVENTION 2017; 13:407-414. [DOI: 10.4244/eij-d-16-00350] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Non-infarct related artery revascularization in ST-segment elevation myocardial infarction patients with multivessel disease. Curr Opin Cardiol 2017; 32:600-607. [PMID: 28617684 DOI: 10.1097/hco.0000000000000427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Multivessel disease (MVD) is common in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) and is associated with significant risk of future cardiovascular (CV) events including short and longer-term mortality. In this review, we examine the pathophysiologic construct contributing to adverse prognosis of MVD in STEMI, relevant available evidence that currently guides the management of the noninfarct-related artery (IRA) stenosis and define the remaining knowledge gaps for future studies. RECENT FINDINGS Results of recent small sized randomized trials, when pooled, suggest improvement in CV outcomes including CV mortality and repeat revascularization with revascularization of the non-IRA stenosis compared with medical management alone. In addition, there does not appear to be an increase in bleeding, contrast-induced nephropathy or stroke, as suggested by earlier observational data. SUMMARY These recent data have led to a Class IIb recommendation in the American College of Cardiology/American Heart Association guidelines stating that non-IRA revascularization may be considered in selected patients with STEMI and MVD who are hemodynamically stable, either at the time of primary PCI or as a planned staged procedure. The ongoing COMPLETE and CULPRIT-SHOCK studies will provide additional data to further inform the role of non-IRA revascularization and its timing in the management of these patients.
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Abnousi F, Sundaram V, Yong CM, Prats J, Deliargyris EN, Stone GW, Hamm CW, Steg PG, Gibson CM, White HD, Price MJ, Généreux P, Desai M, Yang L, Ding VY, Harrington RA, Bhatt DL, Mahaffey KW. Cangrelor reduces the risk of ischemic complications in patients with single-vessel and multi-vessel disease undergoing percutaneous coronary intervention: Insights from the CHAMPION PHOENIX trial. Am Heart J 2017; 188:147-155. [PMID: 28577670 DOI: 10.1016/j.ahj.2017.02.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 02/28/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To examine the safety and efficacy of cangrelor in patients with single-vessel disease (SVD) and multi-vessel disease (MVD). BACKGROUND Cangrelor, an intravenous, rapidly acting P2Y12 inhibitor, is superior to clopidogrel in reducing ischemic events among patients receiving percutaneous coronary intervention (PCI). METHODS We studied a modified intention to treat population of patients with SVD and MVD from the CHAMPION PHOENIX trial. The primary efficacy outcome was the composite of death, myocardial infarction (MI), ischemia-driven revascularization (IDR), and stent thrombosis (ST) at 48hours. The key safety outcome was non-coronary artery bypass grafting GUSTO severe bleeding at 48hours. RESULTS Among 10,921 patients, 5,220 (48%) had SVD and 5,701 (52%) had MVD. MVD patients were older and more often had diabetes, hyperlipidemia, hypertension, prior stroke, and prior MI. After adjustment, MVD patients had similar rates of 48-hour death/MI/IDR/ST (6.3% vs 4.2%, adjusted odds ratio [OR] 1.6 [95% CI 0.42-6.06]) and GUSTO severe bleeding (0.1% vs 0.2%, P=.67) compared with SVD patients. Consistent with overall trial findings, cangrelor use reduced ischemic complications in patients with both SVD (3.9% vs 4.5%; OR 0.86, 95% CI 0.65-1.12) and MVD (5.5% vs 7.2%; OR 0.74, 95% CI 0.6-0.92, P-interaction=.43). GUSTO severe bleeding outcomes were not significantly increased with cangrelor or clopidogrel in either SVD or MVD patients. CONCLUSION In the CHAMPION PHOENIX trial, MVD and SVD patients had similar ischemic outcomes at 48hours and 30days. Cangrelor consistently reduced ischemic complications in both SVD and MVD patients without a significant increase in GUSTO severe bleeding. CLINICAL PERSPECTIVES.
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Bravo CA, Hirji SA, Bhatt DL, Kataria R, Faxon DP, Ohman EM, Anderson KL, Sidi AI, Sketch Jr. MH, Zarich SW, Osho AA, Gluud C, Kelbæk H, Engstrøm T, Høfsten DE, Brennan JM. Complete versus culprit-only revascularisation in ST elevation myocardial infarction with multi-vessel disease. Cochrane Database Syst Rev 2017; 5:CD011986. [PMID: 28470696 PMCID: PMC6481381 DOI: 10.1002/14651858.cd011986.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Multi-vessel coronary disease in people with ST elevation myocardial infarction (STEMI) is common and is associated with worse prognosis after STEMI. Based on limited evidence, international guidelines recommend intervention on only the culprit vessel during STEMI. This, in turn, leaves other significantly stenosed coronary arteries for medical therapy or revascularisation based on inducible ischaemia on provocative testing. Newer data suggest that intervention on both the culprit and non-culprit stenotic coronary arteries (complete intervention) may yield better results compared with culprit-only intervention. OBJECTIVES To assess the effects of early complete revascularisation compared with culprit vessel only intervention strategy in people with STEMI and multi-vessel coronary disease. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, World Health Organization International Clinical Trials Registry Platform Search Portal, and ClinicalTrials.gov. The date of the last search was 4 January 2017. We applied no language restrictions. We handsearched conference proceedings to December 2016, and contacted authors and companies related to the field. SELECTION CRITERIA We included only randomised controlled trials (RCTs), wherein complete revascularisation strategy was compared with a culprit-only percutaneous coronary intervention (PCI) for the treatment of people with STEMI and multi-vessel coronary disease. DATA COLLECTION AND ANALYSIS We assessed the methodological quality of each trial using the Cochrane 'Risk of bias' tool. We resolved the disagreements by discussion among review authors. We followed standard methodological approaches recommended by Cochrane. The primary outcomes were long-term (one year or greater after the index intervention) all-cause mortality, long-term cardiovascular mortality, long-term non-fatal myocardial infarction, and adverse events. The secondary outcomes were short-term (within the first 30 days after the index intervention) all-cause mortality, short-term cardiovascular mortality, short-term non-fatal myocardial infarction, revascularisation, health-related quality of life, and cost. We analysed data using fixed-effect models, and expressed results as risk ratios (RR) with 95% confidence intervals (CI). We used GRADE criteria to assess the quality of evidence and we conducted Trial Sequential Analysis (TSA) to control risks of random errors. MAIN RESULTS We included nine RCTs, that involved 2633 people with STEMI and multi-vessel coronary disease randomly assigned to either a complete (n = 1381) versus culprit-only (n = 1252) revascularisation strategy. The complete and the culprit-only revascularisation strategies did not differ for long-term all-cause mortality (65/1274 (5.1%) in complete group versus 72/1143 (6.3%) in culprit-only group; RR 0.80, 95% CI 0.58 to 1.11; participants = 2417; studies = 8; I2 = 0%; very low quality evidence). Compared with culprit-only intervention, the complete revascularisation strategy was associated with a lower proportion of long-term cardiovascular mortality (28/1143 (2.4%) in complete group versus 51/1086 (4.7%) in culprit-only group; RR 0.50, 95% CI 0.32 to 0.79; participants = 2229; studies = 6; I2 = 0%; very low quality evidence) and long-term non-fatal myocardial infarction (47/1095 (4.3%) in complete group versus 70/1004 (7.0%) in culprit-only group; RR 0.62, 95% CI 0.44 to 0.89; participants = 2099; studies = 6; I2 = 0%; very low quality evidence). The complete and the culprit-only revascularisation strategies did not differ in combined adverse events (51/2096 (2.4%) in complete group versus 57/1990 (2.9%) in culprit-only group; RR 0.84, 95% CI 0.58 to 1.21; participants = 4086; I2 = 0%; very low quality evidence). Complete revascularisation was associated with lower proportion of long-term revascularisation (145/1374 (10.6%) in complete group versus 258/1242 (20.8%) in culprit-only group; RR 0.47, 95% CI 0.39 to 0.57; participants = 2616; studies = 9; I2 = 31%; very low quality evidence). TSA of long-term all-cause mortality, long-term cardiovascular mortality, and long-term non-fatal myocardial infarction showed that more RCTs are needed to reach more conclusive results on these outcomes. Regarding long-term repeat revascularisation more RCTs may not change our present result. The quality of the evidence was judged to be very low for all primary and the majority of the secondary outcomes mainly due to risk of bias, imprecision, and indirectness. AUTHORS' CONCLUSIONS Compared with culprit-only intervention, the complete revascularisation strategy may be superior due to lower proportions of long-term cardiovascular mortality, long-term revascularisation, and long-term non-fatal myocardial infarction, but these findings are based on evidence of very low quality. TSA also supports the need for more RCTs in order to draw stronger conclusions regarding the effects of complete revascularisation on long-term all-cause mortality, long-term cardiovascular mortality, and long-term non-fatal myocardial infarction.
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Affiliation(s)
- Claudio A Bravo
- Albert Einstein College of Medicine, Montefiore Medical CenterMontefiore Einstein Center for Heart & Vascular Care111 East 210th StreetBronxNew YorkUSA10467
| | - Sameer A Hirji
- Brigham and Women's Hospital, Harvard Medical SchoolDepartment of Surgery75 Francis StreetBostonMAUSA02115
| | - Deepak L Bhatt
- Brigham and Women's HospitalHeart & Vascular Centre75 Francis StreetBostonMAUSA02115
| | - Rachna Kataria
- Yale New Haven Health SystemDepartment of Internal Medicine267 Grant StreetBridgeportConnecticutUSA06610
| | - David P Faxon
- Brigham and Women's HospitalCardiovascular MedicineBrigham Circle, 1620BostonMassachusettsUSA02120‐1613
| | - E Magnus Ohman
- Division of Cardiovascular Medicine, Duke Heart Center, Ambulatory CareProgramme for Advanced Coronary DiseasesBox 3126, Room 8676A HAFS BuildingDuke University Medical CenterDurhamNorth CarolinaUSA27710
| | - Kevin L Anderson
- Duke UniversitySchool of Medicine201 Trent DriveDurhamNorth CarolinaUSA27705
| | - Akil I Sidi
- University of North CarolinaDepartment of Biology201 Councilman courtMorrisvilleNorth CarolinaUSA27560
| | - Michael H Sketch Jr.
- Duke University School of MedicineDepartment of Medicine/CardiologyDUMC 3157DurhamNorth CarolinaUSA27710
| | - Stuart W Zarich
- Yale New Haven Health SystemDepartment of Cardiology267 Grant StBridgeportConnecticutUSA06610
| | - Asishana A Osho
- Massachusetts General HospitalGeneral Surgery55 Fruit StreetBostonMAUSA02114
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Henning Kelbæk
- Zealand University, Roskilde HospitalCardiac Catheterization LaboratoryKøgevej 7‐13RoskildeDenmark4000
| | - Thomas Engstrøm
- Copenhagen University Hospital, RigshospitaletDepartment of CardiologyBlegdamsvej 9CopenhagenDenmark2100
| | - Dan Eik Høfsten
- Copenhagen University Hospital, RigshospitaletDepartment of CardiologyBlegdamsvej 9CopenhagenDenmark2100
| | - James M Brennan
- Duke University School of MedicineDepartment of Medicine/CardiologyDUMC 3157DurhamNorth CarolinaUSA27710
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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.
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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
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Shah R, Clare RM, Chiswell K, Jones WS, Kumar AS, Thiele H, Smalling RW, Chandra P, Cohen M, Perera D, Chew DP, French JK, Blaxill J, Ohman EM, Patel MR. Impact of Non-Infarct-Related Artery Disease on Infarct Size and Outcomes (from the CRISP-AMI Trial). Am J Med 2016; 129:1307-1315. [PMID: 27542611 DOI: 10.1016/j.amjmed.2016.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 07/25/2016] [Accepted: 07/25/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Non-infarct-related artery (non-IRA) disease is prevalent in patients with ST-segment elevation myocardial infarction (STEMI). We aimed to assess the impact of non-IRA disease on infarct size and clinical outcomes in patients with acute STEMI. METHODS The Counterpulsation to Reduce Infarct Size Pre-PCI Acute Myocardial Infarction (CRISP-AMI) trial randomized patients to intra-aortic balloon counterpulsation (IABC) vs no IABC prior to percutaneous coronary intervention in patients with acute STEMI. Infarct size (% left ventricular mass) at 3-5 days post percutaneous coronary intervention and 6-month clinical outcomes were compared between patients with and without non-IRA disease (defined as ≥50% stenosis in at least one non-IRA). RESULTS A total of 324 (96.1%) patients had anterior STEMI, of whom 34.9% had non-IRA disease. There was no difference in infarct size (% left ventricular mass) between patients with and without non-IRA disease (median 39% vs 39%; P = .73). At 6 months, there was no difference in rates of recurrent myocardial infarction (0.9% vs 0.9%; P = .78), major Thrombolysis In Myocardial Infarction bleeding (0.9% vs 0.5%; P = .77), or all-cause death (3.5% vs 2.4%; P = .61) in patients with and without non-IRA disease, respectively. Patients with non-IRA disease had a higher rate of new/worsening heart failure with hospitalization (8.8% vs 1.9%; P = .0050). CONCLUSIONS More than one-third of patients with anterior STEMI in the CRISP-AMI study had non-IRA disease. These patients had similar infarct sizes and rates of recurrent myocardial infarction, major bleeding, and all-cause death. Patients with non-IRA disease did have a higher rate of new/worsening heart failure with hospitalization. Further study is needed to understand the mechanisms of outcomes of patients with non-IRA disease.
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Affiliation(s)
- Rohan Shah
- Duke Clinical Research Institute, Durham, NC
| | | | | | - W Schuyler Jones
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - A Sreenivas Kumar
- Department of Cardiovascular Sciences, Citizens Hospitals, Hyderabad, India
| | - Holger Thiele
- Medical Clinic II, University Heart Center Lübeck, Germany
| | - Richard W Smalling
- Division of Cardiology, Memorial Hermann Heart and Vascular Institute, University of Texas, Houston
| | - Praveen Chandra
- Division of Cardiology, Medanta - the Medicity, Haryana, India
| | - Marc Cohen
- Division of Cardiology, Newark Beth Israel Medical Center, NJ
| | - Divaka Perera
- Cardiovascular Division, King's College, London, England
| | - Derek P Chew
- Department of Cardiovascular Medicine, Flinders Medical Center, Bedford Park, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, Australia
| | | | - E Magnus Ohman
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Manesh R Patel
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC.
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Comparison of In-Hospital Mortality, Length of Stay, Postprocedural Complications, and Cost of Single-Vessel Versus Multivessel Percutaneous Coronary Intervention in Hemodynamically Stable Patients With ST-Segment Elevation Myocardial Infarction (from Nationwide Inpatient Sample [2006 to 2012]). Am J Cardiol 2016; 118:950-8. [PMID: 27522303 DOI: 10.1016/j.amjcard.2016.06.057] [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] [Received: 02/15/2016] [Revised: 06/30/2016] [Accepted: 06/30/2016] [Indexed: 12/22/2022]
Abstract
The primary objective of our study was to evaluate the in-hospital outcomes in terms of mortality, procedural complications, hospitalization costs, and length of stay (LOS) after multivessel percutaneous coronary intervention (MVPCI) in hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI). The study cohort was derived from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database, years 2006 to 2012. Percutaneous coronary interventions (PCI) performed during STEMI were identified using appropriate International Classification of Diseases, Ninth Revision, diagnostic and procedural codes. Patients in cardiogenic shock were excluded. Hierarchical mixed-effects logistic regression models were used for categorical dependent variables such as in-hospital mortality and composite of in-hospital mortality and complications, and hierarchical mixed-effects linear regression models were used for continuous dependent variables such as cost of hospitalization and LOS. We identified 106,317 (weighted n = 525,161) single-vessel PCI and 15,282 (weighted n = 74,543) MVPCIs. MVPCI (odds ratio, 95% confidence interval [CI], p value) was not associated with significant increase in in-hospital mortality (0.99, 0.85 to 1.15, 0.863) but predicted a higher composite end point of in-hospital mortality and postprocedural complications (1.09, 1.02 to 1.17, 0.013) compared to single-vessel PCI. MVPCI was also predictive of longer LOS (LOS +0.19 days, 95% CI +0.14 to +0.23 days, p <0.001) and higher hospitalization costs (cost +$4,445, 95% CI +$4,128 to +$4,762, p <0.001). MVPCI performed during STEMI in hemodynamically stable patients is associated with no increase in in-hospital mortality but a higher rate of postprocedural complications and longer LOS and greater hospitalization costs compared to single-vessel PCI.
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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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Abstract
Primary PCI of infarct-related arteries is the preferred reperfusion strategy in patients presenting with ST-segment elevation myocardial infarction (STEMI). Up to 40 % of such patients demonstrate evidence of multivessel, non-infarct-related artery coronary disease. Previous non-randomised observational studies and their associated meta-analyses have suggested that in such cases only the culprit infarct-related artery (IRA) lesion should be treated. However, recent randomised controlled trials have demonstrated improved clinical outcomes with lower major adverse cardiovascular events (MACE) rates when complete revascularisation is undertaken either at index primary percutaneous coronary intervention (PPCI) or during index admission. These trials suggest that current guidelines pertaining to treatment of non-infarct-related artery (N-IRA) lesions in STEMI patients with multivessel disease may need to be reconsidered depending on future trials. However, issues remain around timing of N-IRA intervention, the use of fractional flow reserve (FFR) or intravascular imaging to guide intervention in N-IRA lesions and the need to demonstrate reductions in hard clinical endpoints (death and MI) after complete revascularisation; these issues will need to be addressed through future trials. Clinicians must judge on the currently available data, whether it is still safer to leave important stenosis in N-IRA untreated.
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Affiliation(s)
- Amerjeet S. Banning
- />Department of Cardiovascular Sciences, University of Leicester Glenfield Hospital, Groby Road, Leicester, LE3 9QP UK
| | - Anthony H. Gershlick
- />Department of Cardiovascular Sciences, University of Leicester Glenfield Hospital, Groby Road, Leicester, LE3 9QP UK
- />Department of Cardiology, University Hospitals of Leicester NHS Trust Glenfield Hospital, Groby Road, Leicester, LE3 9QP UK
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Anantha Narayanan M, Reddy YN, Sundaram V, Reddy YN, Baskaran J, Agnihotri K, Badheka A, Patel N, Deshmukh A. What is the optimal approach to a non- culprit stenosis after ST-elevation myocardial infarction — Conservative therapy or upfront revascularization? An updated meta-analysis of randomized trials. Int J Cardiol 2016; 216:18-24. [DOI: 10.1016/j.ijcard.2016.04.054] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 04/10/2016] [Indexed: 11/26/2022]
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Dönmez E, Koç M, Şeker T, İçen YK, Çayli M. The assessment of non culprit coronary artery lesions in patients with ST segment elevated myocardial infarction and multivessel disease by control angiography with quantitative coronary angiography. Int J Cardiovasc Imaging 2016; 32:1471-6. [DOI: 10.1007/s10554-016-0943-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 07/16/2016] [Indexed: 01/25/2023]
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Chung WY, Seo JB, Choi DH, Cho YS, Lee JM, Suh JW, Youn TJ, Chae IH, Choi DJ. Immediate multivessel revascularization may increase cardiac death and myocardial infarction in patients with ST-elevation myocardial infarction and multivessel coronary artery disease: data analysis from real world practice. Korean J Intern Med 2016; 31:488-500. [PMID: 27048252 PMCID: PMC4855085 DOI: 10.3904/kjim.2014.119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 10/09/2014] [Accepted: 03/11/2015] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND/AIMS The best revascularization strategy for patients with both acute ST-elevation myocardial infarction (STEMI) and multivessel coronary disease (MVD) is still debatable. We aimed to compare the outcomes of multivessel revascularization (MVR) with those of culprit-only revascularization (COR). METHODS A cohort of 215 consecutive patients who had received primary angioplasty for STEMI and MVD were divided into two groups according to whether angioplasty had been also performed for a stenotic nonculprit artery. The primary endpoint was one-year major adverse cardiac events defined as a composite of cardiac death, recurrent myocardial infarction, or any repeat revascularization. RESULTS One-year major adverse cardiac events were not significantly different between MVR (n = 107) and COR (n = 108) groups. However, the one-year composite hard endpoint of cardiac death or recurrent myocardial infarction was notably increased in the MVR group compared to the COR group (20.0% vs. 8.9%, p = 0.024). In subgroup analysis, the hard endpoint was significantly more frequent in the immediate than in the staged MVR subgroup (26.6% vs. 9.8%, p = 0.036). The propensity score-matched cohorts confirmed these findings. CONCLUSIONS In patients with STEMI and MVD, MVR, especially immediate MVR with primary percutaneous intervention, was not beneficial and led to worse outcomes. Therefore, we conclude that COR or staged MVR would be better strategies for patients with STEMI and MVD.
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Affiliation(s)
- Woo-Young Chung
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jae-Bin Seo
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Dong-Hyun Choi
- Department of Internal Medicine, Chosun University Hospital, Gwangju, Korea
| | - Young-Seok Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Correspondence to Young-Seok Cho, M.D. Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea Tel: +82-31-787-7018 Fax: +82-31-787-4051 E-mail:
| | - Joo Myung Lee
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jung-Won Suh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Tae-Jin Youn
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - In-Ho Chae
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dong-Ju Choi
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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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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Soverow J, Parikh MA. Acute Myocardial Infarction/Thrombectomy. Interv Cardiol Clin 2016; 5:259-269. [PMID: 28582209 DOI: 10.1016/j.iccl.2015.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
This article focuses on specialized techniques and devices used in the most challenging cases of acute myocardial infarction. Areas where high-quality evidence is either clear or absent are avoided. Controversies in the use of support or thrombectomy devices, the addition of adjunct pharmacology, and the decision to treat nonculprit lesions are discussed. Recent years have seen a shift in guidelines to downgrading the use of assist devices in cardiogenic shock and aspiration thrombectomy, whereas consideration of nonculprit coronary intervention has been revived. These changes come in the wake of a series of large, practice-changing clinical trials.
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Affiliation(s)
- Jonathan Soverow
- Center for Interventional Vascular Therapy, Columbia-Presbyterian Hospital, 161 Fort Washington Avenue, Herbert Irving Pavilion, 6th Floor, New York, NY 10032, USA.
| | - Manish A Parikh
- Center for Interventional Vascular Therapy, Columbia-Presbyterian Hospital, 161 Fort Washington Avenue, Herbert Irving Pavilion, 6th Floor, New York, NY 10032, USA
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Loutfi M, Ayad S, Sobhy M. Impact of the Residual SYNTAX Score on Outcomes of Revascularization in Patients with ST-Segment Elevation Myocardial Infarction and Multivessel Disease. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2016; 10:29-35. [PMID: 26997875 PMCID: PMC4786097 DOI: 10.4137/cmc.s35730] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 12/22/2015] [Accepted: 01/04/2016] [Indexed: 11/22/2022]
Abstract
Primary percutaneous coronary intervention (P-PCI) has become the preferred reperfusion strategy in ST-elevation myocardial infarction (STEMI) when performed by an experienced team in a timely manner. However, no consensus exists regarding the management of multivessel coronary disease detected at the time of P-PCI.
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Affiliation(s)
- Mohamed Loutfi
- Department of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Sherif Ayad
- Department of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Mohamed Sobhy
- Department of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Saad M, Rashed A, El-Kilany W, El-Haddad M, Elgendy IY. Preliminary Report on the Safety and Efficacy of Staged versus Complete Revascularization in Patients with Multivessel Disease at the Time of Primary Percutaneous Coronary Intervention. Int J Angiol 2016; 26:143-147. [PMID: 28804231 DOI: 10.1055/s-0036-1572522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
This study aims to determine the safety and efficacy of complete versus staged-percutaneous coronary intervention (PCI) of nonculprit lesions at the time of primary PCI in patients with multivessel disease. Recent trials had suggested that revascularization of nonculprit lesions at the time of primary PCI is associated with better outcomes, however; the optimum timing and overall safety of this approach is not well known. An observational prospective study was conducted, including 50 patients who presented with ST-segment elevation myocardial infarction and found to have at least an additional nonculprit significant (> 70%) type A or B lesion. According to the operator's discretion, patients either underwent complete revascularization of nonculprit significant lesions during primary PCI procedure or within 60 days of primary PCI (staged-PCI). Safety outcomes evaluated were contrast-induced nephropathy (CIN), the amount of contrast used, and fluoroscopy time. Efficacy outcome assessed was major adverse events (MACE) at 1 year. The fluoroscopy time and amount of contrast used were increased in complete revascularization group (35.3 ± 9.6 vs. 26.3 ± 6.7 minutes, p < 0.001, and 219.5 ± 35.1 vs. 187.5 ± 45.5 mL, p = 0.01, respectively); while incidence of CIN remained similar ( p = 0.73). The incidence of MACE at 1 year was similar in both groups (23% in the complete revascularization group vs. 25% in the staged-PCI group, p = 0.43). Complete revascularization and staged-PCI of nonculprit type A or B lesions at the time of primary PCI were associated with similar long-term outcomes and safety profile. Larger studies are needed to further validate these results.
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Affiliation(s)
- Marwan Saad
- Department of Medicine, Seton Hall University School of Health and Medical Sciences, Trinitas Regional Medical Center, Elizabeth, New Jersey.,Department of Cardiovascular Diseases, Ain Shams University, Cairo, Egypt
| | - Ahmed Rashed
- Department of Cardiovascular Diseases, Wayne State University School of Medicine, Detroit Medical Center, Detroit, Michigan
| | - Wael El-Kilany
- Department of Cardiovascular Diseases, Ain Shams University, Cairo, Egypt
| | - Mohamed El-Haddad
- Department of Cardiovascular Diseases, University of Vermont, Burlington, Vermont
| | - Islam Y Elgendy
- Department of Cardiovascular Diseases, University of Florida, Gainesville, Florida
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de Waha S, Eitel I, Desch S, Fuernau G, Pöss J, Schuler G, Thiele H. Impact of multivessel coronary artery disease on reperfusion success in patients with ST-elevation myocardial infarction: A substudy of the AIDA STEMI trial. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2015; 6:592-600. [DOI: 10.1177/2048872615624240] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Suzanne de Waha
- University Heart Centre Lübeck, University Hospital Schleswig-Holstein, Germany
| | - Ingo Eitel
- University Heart Centre Lübeck, University Hospital Schleswig-Holstein, Germany
| | - Steffen Desch
- University Heart Centre Lübeck, University Hospital Schleswig-Holstein, Germany
| | - Georg Fuernau
- University Heart Centre Lübeck, University Hospital Schleswig-Holstein, Germany
| | - Janine Pöss
- University Heart Centre Lübeck, University Hospital Schleswig-Holstein, Germany
| | - Gerhard Schuler
- Department of Internal Medicine – Cardiology, University of Leipzig – Heart Centre, Germany
| | - Holger Thiele
- University Heart Centre Lübeck, University Hospital Schleswig-Holstein, Germany
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Bajaj NS, Kalra R, Aggarwal H, Ather S, Gaba S, Arora G, McGiffin DC, Ahmed M, Aslibekyan S, Arora P. Comparison of Approaches to Revascularization in Patients With Multivessel Coronary Artery Disease Presenting With ST-Segment Elevation Myocardial Infarction: Meta-analyses of Randomized Control Trials. J Am Heart Assoc 2015; 4:e002540. [PMID: 26667087 PMCID: PMC4845262 DOI: 10.1161/jaha.115.002540] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 10/23/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Significant controversy exists regarding the best approach for nonculprit vessel revascularization in patients with multivessel coronary artery disease presenting with ST-segment elevation myocardial infarction. We conducted a systematic investigation to pool data from current randomized controlled trials (RCTs) to assess optimal treatment strategies in this patient population. METHODS AND RESULTS A comprehensive search of SCOPUS from inception through May 2015 was performed using predefined criteria. We compared efficacy and safety outcomes of different approaches by categorizing the studies into 3 groups: (1) complete revascularization (CR) versus culprit lesion revascularization (CL) at index hospitalization, (2) CR at index hospitalization versus staged revascularization (SR) of nonculprit vessels at a separate hospitalization, and (3) comparison of SR versus CL. Eight eligible RCTs met the inclusion criteria: (1) CR versus CL (6 RCTs, n=1727) (2) CR versus SR (3 RCTs, n=311), and (3) SR versus CL (1 RCT, n=149). We observed significantly lower rates of major adverse cardiovascular events, revascularization, and repeat percutaneous coronary interventions among patients treated with CR and SR compared with a CL approach (P<0.05). The rates of all-cause mortality, cause-specific mortality, major bleeding, reinfarction, stroke, and contrast-induced nephropathy did not differ in the CR arm compared with the CL arm. The rates of these outcomes were similar in the CR and SR arms. CONCLUSION Results suggest that CR and SR compared with CL reduce major adverse cardiovascular event and revascularization rates primarily by lowering repeated percutaneous coronary intervention rates. We did not observe any increase in the rate of adverse events while using a CR or SR strategy compared with a CL approach. Current guidelines discouraging CR need to be reevaluated, and clinical judgment should prevail in treating multivessel coronary artery disease patients with ST-segment elevation myocardial infarction as data from larger RCTs accumulate.
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Affiliation(s)
- Navkaranbir S. Bajaj
- Division of CardiologyDepartment of MedicineUniversity of Alabama at BirminghamAL
- Ryals School of Public HealthDepartment of EpidemiologyUniversity of Alabama at BirminghamAL
| | - Rajat Kalra
- Department of MedicineUniversity of Alabama at BirminghamAL
| | - Himanshu Aggarwal
- Division of CardiologyDepartment of MedicineUniversity of Alabama at BirminghamAL
| | - Sameer Ather
- Division of CardiologyDepartment of MedicineUniversity of Alabama at BirminghamAL
| | - Saurabh Gaba
- Division of CardiologyDepartment of MedicineUniversity of Alabama at BirminghamAL
| | - Garima Arora
- Division of CardiologyDepartment of MedicineUniversity of Alabama at BirminghamAL
| | | | - Mustafa Ahmed
- Division of CardiologyDepartment of MedicineUniversity of Alabama at BirminghamAL
- Division of CardiologyBaptist PrincetonBirminghamAL
| | - Stella Aslibekyan
- Ryals School of Public HealthDepartment of EpidemiologyUniversity of Alabama at BirminghamAL
| | - Pankaj Arora
- Division of CardiologyDepartment of MedicineUniversity of Alabama at BirminghamAL
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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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Salem M. Multivessel Stenting versus Culprit-Only Stenting in Multivessel Coronary Artery Disease Patients Presented with Non-ST-Segment Elevation Acute Coronary Syndrome (NSTE-ACS). ACTA ACUST UNITED AC 2015. [DOI: 10.15406/jccr.2015.03.00122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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46
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Arora S, Panaich SS, Patel NJ, Patel N, Solanki S, Deshmukh A, Singh V, Lahewala S, Savani C, Thakkar B, Dave A, Patel A, Bhatt P, Sonani R, Patel A, Cleman M, Forrest JK, Schreiber T, Badheka AO, Grines C. Multivessel Percutaneous Coronary Interventions in the United States. Angiology 2015; 67:326-35. [DOI: 10.1177/0003319715593853] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background: Multivessel coronary artery disease carries significant mortality risk. Comprehensive data on inhospital outcomes following multivessel percutaneous coronary intervention (MVPCI) are sparse. Methods: We queried the Healthcare Cost and Utilization Project’s nationwide inpatient sample (NIS) between 2006 and 2011 using different International Classification of Diseases, 9th Revision, Clinical Modification procedure codes. The primary outcome was inhospital all-cause mortality, and the secondary outcome was a composite of inhospital mortality and periprocedural complications. Results: The overall mortality was low at 0.73% following MVPCI. Multivariate analysis revealed that (odds ratio, 95% confidence interval, P value) age (1.63, 1.48-1.79; <.001), female sex (1.19, 1.00-1.42; P = .05), acute myocardial infarction (AMI; 2.97, 2.35-3.74; <.001), shock (17.24, 13.61-21.85; <.001), a higher burden of comorbidities (2.09, 1.32-3.29; .002), and emergent/urgent procedure status (1.67, 1.30-2.16; <.001) are important predictors of primary and secondary outcomes. MVPCI was associated with higher mortality, length of stay (LOS), and cost of care as compared to single vessel single stent PCI. Conclusion: MVPCI is associated with higher inhospital mortality, LOS, and hospitalization costs compared to single vessel, single stent PCI. Higher volume hospitals had lower overall postprocedural mortality rate along with shorter LOS and lower hospitalization costs following MVPCI.
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Affiliation(s)
- Shilpkumar Arora
- Internal Medicine Department, Mount Sinai St Luke’s Roosevelt Hospital, New York, NY, USA
| | | | - Nileshkumar J. Patel
- Internal Medicine Department, Staten Island University Hospital, Staten Island, NY, USA
| | - Nilay Patel
- Internal Medicine Department, Saint Peter’s University Hospital, New Brunswick, NJ, USA
| | - Shantanu Solanki
- Internal Medicine Department, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Vikas Singh
- Cardiology Department, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Sopan Lahewala
- Internal Medicine Department, Mount Sinai Hospital Center, New York, NY, USA
| | - Chirag Savani
- Internal Medicine Department, New York Medical College, Valhalla, NY, USA
| | - Badal Thakkar
- Internal Medicine Department, Tulane University School of Public Health & Tropical Medicine, New Orleans, LA, USA
| | - Abhishek Dave
- Internal Medicine Department, Texas A&M University, College Station, TX, USA
| | - Achint Patel
- Internal Medicine Department, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Parth Bhatt
- Internal Medicine Department, Tulane University School of Public Health & Tropical Medicine, New Orleans, LA, USA
| | - Rajesh Sonani
- Internal Medicine Department, Emory University School of Medicine, Atlanta, GA, USA
| | - Aashay Patel
- Internal Medicine Department, Lankenau Institute for Medical Research, Wynnewood, PA, USA
| | - Michael Cleman
- Cardiology Department, Yale School of Medicine, New Haven, CT, USA
| | - John K. Forrest
- Cardiology Department, Yale School of Medicine, New Haven, CT, USA
| | | | | | - Cindy Grines
- Cardiovascular Department, Detroit Medical Center, Detroit, MI, USA
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Meta-Analysis of the Impact on Mortality of Noninfarct-Related Artery Coronary Chronic Total Occlusion in Patients Presenting With ST-Segment Elevation Myocardial Infarction. Am J Cardiol 2015; 116:8-14. [PMID: 26068700 DOI: 10.1016/j.amjcard.2015.03.031] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 03/24/2015] [Accepted: 03/24/2015] [Indexed: 01/02/2023]
Abstract
Several observational studies have compared clinical outcome in patients with a co-existing noninfarct-related artery chronic total occlusion (n-IRA CTO) versus those without, suggesting increased all-cause mortality. The goal of this study was to provide a systematic review and meta-analysis evaluating the impact of the presence of an n-IRA CTO on short- and long-term mortality after primary percutaneous coronary intervention. Studies published from January 1980 to January 2014 that compared the incidence of all-cause mortality in patients with ST-segment elevation myocardial infarction with co-existing n-IRA CTO versus those without were identified using an electronic search and reviewed using meta-analytical techniques. Seven studies (5 observational studies and 2 observational analyses of randomized controlled trials) comprising 14,117 patients and 1,554 patients (11.7%) with n-IRA CTO were included. The presence of n-IRA CTO was associated with increased incidence of all-cause mortality at a median follow-up of 25.2 months (interquartile range 24 to 60) compared with no CTO (absolute risk 23.5% vs 9.0%; odds ratio [OR] 2.90, 95% confidence interval [CI] 2.09 to 4.01; p <0.0001). This finding was consistent in the analysis of studies reporting 30-day follow-up (absolute risk 17.2% vs 4.7%; OR 3.79, 95% CI 3.13 to 4.59; p <0.0001). Co-existing n-IRA CTO was also associated with increased mortality in a subanalysis of patients with multivessel disease only (absolute risk 24.2% vs 11.3%; OR 2.23, 95% CI 1.90 to 2.63; p <0.0001). In conclusion, coronary CTO in the nonculprit artery in patients presenting with ST-segment elevation myocardial infarction is associated with increased short- and long-term all-cause mortality.
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48
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Fractional Flow Reserve in Acute Myocardial Infarction: A Guide for Non-Culprit Lesions? Cardiol Ther 2015; 4:39-46. [PMID: 26055262 PMCID: PMC4472643 DOI: 10.1007/s40119-015-0040-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Indexed: 01/10/2023] Open
Abstract
In patients presenting with ST-segment elevation myocardial infarction (STEMI) and multi-vessel disease (MVD), the optimal therapy for non-culprit lesions is still a matter of debate. While guidelines discourage a concomitant treatment of infarct- and non-infarct-related arteries, recent studies document advantages of a complete (preventive) revascularization during primary percutaneous coronary intervention. Such an approach, however, may result in overtreatment, because angiography does not provide robust information about the functional severity of MVD. Fractional flow reserve (FFR) measurements can be a valuable guide for non-culprit lesions in acute myocardial infarction, but so far, only the reliability and safety of FFR measurements have been established in this setting. The clinical implications of an FFR-guided treatment strategy in STEMI patients with MVD are currently being tested in a large randomized trial.
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Kowalewski M, Schulze V, Berti S, Waksman R, Kubica J, Kołodziejczak M, Buffon A, Suryapranata H, Gurbel PA, Kelm M, Pawliszak W, Anisimowicz L, Navarese EP. Complete revascularisation in ST-elevation myocardial infarction and multivessel disease: meta-analysis of randomised controlled trials. Heart 2015; 101:1309-17. [DOI: 10.1136/heartjnl-2014-307293] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 05/08/2015] [Indexed: 01/08/2023] Open
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50
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The Third DANish Study of Optimal Acute Treatment of Patients with ST-segment Elevation Myocardial Infarction: Ischemic postconditioning or deferred stent implantation versus conventional primary angioplasty and complete revascularization versus treatment of culprit lesion only: Rationale and design of the DANAMI 3 trial program. Am Heart J 2015; 169:613-21. [PMID: 25965708 DOI: 10.1016/j.ahj.2015.02.004] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 02/05/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND In patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction, ischemic postconditioning has been shown to reduce infarct size, but the effect on clinical outcome has not been tested in a large randomized trial. In addition, deferring stent implantation in the infarct-related lesion 1 to 3 days after acute opening of the infarct-related artery could have protective effects, by reducing the risk of injury caused by distal embolization and microvascular obstruction. Finally, a considerable fraction of patients present with lesions in other coronary artery branches than the infarct-related artery. Whether a strategy of complete or partial revascularization of these patients should be preferred remains uncertain. STUDY DESIGN The DANAMI 3 trial program was designed to investigate 3 different randomized treatment strategies in patients with ST-segment elevation myocardial infarction: (1) ischemic postconditioning versus conventional treatment with a primary end point of death and hospitalization for heart failure; (2) deferring stent implantation in the infarct-related lesion versus conventional treatment with a primary end point of death, hospitalization for heart failure, reinfarction, and repeat revascularization; and (3) treatment of the culprit lesion only versus fractional flow reserve-guided complete revascularization in patients with multivessel disease, with a primary end point of death, reinfarction, and repeat revascularization. SUMMARY The DANAMI 3 trial program will determine whether either of 2 approaches to reduce reperfusion injury and distal microvascular obstruction with postconditioning or deferred stent implantation will translate into improved clinical outcome and whether patients with multivessel disease undergoing primary percutaneous coronary intervention will benefit from a strategy of complete or partial revascularization.
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