What is the frequency and functional and clinical significance of complex lesions in non-infarct-related arteries after fibrinolysis for acute ST-elevation myocardial infarction?

The Inhibition of Evolocumab on Non-Infarct-Related Artery Disease in Patients with ST-Elevation Myocardial Infarction

Purpose

The effects of combing evolocumab and statin on the clinical outcome and physiological function of coronary arteries in STEMI patients with non-infarct-related artery (NIRA) disease are still unclear.

Methods

A total of 355 STEMI patients with NIRA were enrolled in this study, who underwent combined quantitative flow ratio (QFR) at baseline and after 12 months of treatment with statin monotherapy or statin plus evolocumab.

Results

Diameter stenosis and lesion length were significantly lower in the group undergoing statin plus evolocumab. While the group exhibited significantly higher minimum lumen diameter (MLD), and QFR values. Statin plus evolocumab (OR = 0.350; 95% CI: 0.149-0.824; P = 0.016) and plaque lesion length (OR = 1.223; 95% CI: 1.102-1.457; P = 0.033) were independently associated with rehospitalization for unstable angina (UA) within 12 months.

Conclusion

Evolocumab combined with statin therapy can significantly improve the anatomical and physiological function of the coronary arteries and downregulate the re-hospitalization rate due to UA in STEMI patients with NIRA.

Staged revascularization vs. culprit-only percutaneous coronary intervention for multivessel disease in elderly patients with ST-segment elevation myocardial infarction

Backgroundand objective

Studies have highlighted the significant role of staged percutaneous coronary intervention (PCI) for a multivessel disease (MVD) among patients with ST-elevation myocardial infarction (STEMI). However, the relative benefit of staged vs. culprit-only PCI for MVD in elderly patients with STEMI remains undetermined. Thus, the present study compared the clinical outcomes of staged and culprit-only PCI in this cohort.

Methods

From January 2014 to September 2019, 617 patients aged ≥65 years with STEMI and MVD who underwent primary PCI of the culprit vessels within 12 h of symptom onset were enrolled. They were then categorized into the staged and culprit-only PCI groups according to intervention strategy. Propensity score matching (PSM) was conducted to adjust for confounding factors between groups. The primary end point was major adverse cardiac and cerebrovascular events (MACCE), a composite of all-cause death, cardiac death, recurrent myocardial infarction (MI), stroke, and ischemia-driven revascularization.

Results

During a mean follow-up of 56 months, 209 patients experienced MACCE and 119 died. Staged revascularization was associated with a lower risk of MACCE, all-cause death, and cardiac death than culprit-only PCI in both overall patients and the PSM cohorts. In contrast, there was no significant difference in stroke or ischemia-driven revascularization. Moreover, on multivariate Cox regression analysis, staged PCI was a significant predictor of a lower incidence of MACCE and all-cause death.

Conclusion

In elderly patients with STEMI and MVD, staged PCI is superior to culprit-only PCI.

Complete Revascularization in Patients With STEMI and Multi-Vessel Disease: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Percutaneous coronary intervention (PCI) is the treatment of choice for ST-elevation myocardial infarction (STEMI). However, efficacy of complete vs culprit only revascularization in patients with STEMI and multivessel disease remains unclear.

METHODS

We searched PubMed/MEDLINE, and Cochrane library. The primary endpoint was major adverse cardiovascular events (MACE). Secondary outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction (MI), repeat revascularization, stroke, major bleeding, and contrast induced nephropathy. Estimates were calculated as random effects hazard ratios (HRs) with 95% confidence intervals (CI).

RESULTS

Twelve trials with 7592 patients were included. There was a significantly lower risk of MACE [HR 0.61; 95% CI (0.43-0.60); p = 0.0009; I² = 72%], cardiovascular mortality [HR 0.74; 95% CI (0.56-0.99); p = 0.04; I² = 2%], and repeat revascularization [HR 0.43; 95% CI (0.31-0.59); p < 0.00001; I² = 67%] in patients treated with complete compared with culprit-only revascularization. There was no statistically significant difference in MI [HR 0.77; 95% CI (0.52-1.12); p = 0.17; I² = 49%], all-cause mortality [HR 0.86; 95% CI (0.65-1.13); p = 0.28; I² = 14%], heart failure [HR 0.82 95% CI (0.51-1.32); p = 0.42; I² = 26%], major bleeding [HR 1.07; 95% CI (0.66-1.75); p = 0.78; I² = 25%], stroke [HR 0.67; 95% CI (0.24-1.89); p = 0.45; I² = 54%], or contrast induced nephropathy, although higher contrast volumes were used in the complete revascularization group [HR 1.22; 95% CI (0.78-1.92); p = 0.39; I² = 0%].

CONCLUSION

Complete revascularization was associated with a significantly lower risk of MACE, cardiovascular mortality, and repeat revascularization compared with culprit-only revascularization. These results suggest complete revascularization with PCI following STEMI and multivessel disease should be considered.

Effects of incretin treatment on cardiovascular outcomes in diabetic STEMI-patients with culprit obstructive and multivessel non obstructive-coronary-stenosis

BACKGROUND

No proper data on prognosis and management of type-2 diabetic ST elevation myocardial infarction (STEMI) patients with culprit obstructive lesion and multivessel non obstructive coronary stenosis (Mv-NOCS) exist. We evaluated the 12-months prognosis of Mv-NOCS-diabetics with first STEMI vs.to non-diabetics, and then Mv-NOCS-diabetics previously treated with incretin based therapy vs. a matched cohort of STEMI-Mv-NOCS never treated with such therapy.

METHODS

1088 Patients with first STEMI and Mv-NOCS were scheduled for the study. Patients included in the study were categorized in type 2 diabetics (n 292) and non-diabetics (n 796). Finally, we categorized diabetics in current-incretin-users (n 76), and never-incretin-users (n 180). The primary end point was all cause deaths, cardiac deaths, and major adverse cardiac events (MACE) at 12 months of follow up.

RESULTS

The study results evidenced higher percentage of all cause deaths (2.2% vs. 1.1%, p value 0.05), cardiac deaths (1.6% vs. 0.5%, p value 0.045), and MACE (12.9% vs. n 5.9%), p value 0.001) in diabetic vs. no diabetic patients at 12 months follow up. Among diabetic patients, the current vs never-incretin-users, did not present a significant difference about all cause of deaths, and cardiac deaths through 12-months. The MACE rate at 1 year was 7.4% in diabetic incretin-users STEMI Mv-NOCS patients vs. 12.9% in diabetic never-incretin-users STEMI-Mv-NOCS patients (p value 0.04). In a risk-adjusted hazard analysis, MACE through 12 months were lower in diabetic STEMI-Mv NOCS incretin-users vs never-incretin-users patients (HR 0.513, CI [0.292-0.899], p 0.021). Consequently, lower levels of glucagon-like peptide 1(GLP-1) were predictive of MACE at follow up (HR 1.528, CI [1.059-2.204], p 0.024).

CONCLUSION

In type 2 diabetic patients with STEMI-Mv-NOCS, we observed higher incidence of 1-year mortality and adverse cardiovascular outcomes, as compared to non-diabetic STEMI-Mv-NOCS patients. In diabetic patients, never-incretin-users have worse prognosis as compared to current-incretin-users.Trail registration Clinical trial number: NCT03312179, name of registry: clinicaltrialgov, URL: clinicalltrialgov.com, date of registration: September 2017, date of enrollment first participant: September 2009.

Instantaneous wave-free ratio and fractional flow reserve for the assessment of nonculprit lesions during the index procedure in patients with ST-segment elevation myocardial infarction: The WAVE study

BACKGROUND

Functional assessment of non-infarct-related artery lesions during primary percutaneous coronary intervention (PCI) might be useful to avoid revascularization of nonsignificant stenosis and staged procedures, thus reducing hospital stay. We aimed to assess the diagnostic performance of instantaneous wave-free ratio (iFR) as compared with fractional flow reserve (FFR) in this setting.

METHODS

In the WAVE study, a prospective, observational, single-center registry (NCT02869906), paired iFR and FFR measurements were performed at the level of non-IRA lesions in patients with ST-segment elevation myocardial infarction both during primary PCI and during staged procedures (5-8 days after).

RESULTS

Paired iFR and FFR measurements were available for 66 non-IRA lesions in 50 patients. The iFR and FFR values of non-IRA lesions did not change significantly between the index and staged procedure. Bland-Altman analysis did not show systematic bias for either iFR or FFR repeated measures. Receiver operating characteristic curve analysis showed high accuracy of iFR to identify positive (≤0.80) FFR measurements in the index procedure with an area under the curve of 0.95. A cutoff of ≤0.89 for iFR in the index procedure had the best combination of sensitivity (95%) and specificity (90%) with positive and negative predictive values of 86% and 97%, respectively. Finally, iFR measured during the index procedure was significantly correlated with FFR (r=0.71, r²=0.51; P<.0001).

CONCLUSIONS

The WAVE study shows that iFR yields similar diagnostic accuracy to FFR in functional evaluation of non-IRA stenosis in patients with STEMI and multivessel CAD, with the advantage of being adenosine free.

Impact of Non-Infarct-Related Artery Disease on Infarct Size and Outcomes (from the CRISP-AMI Trial)

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.

Safety and Efficacy of Staged Percutaneous Coronary Intervention During Index Admission for ST-Elevation Myocardial Infarction With Multivessel Coronary Disease (Insights from the University of Ottawa Heart Institute STEMI Registry)

The optimal management strategy for patients with ST-elevation myocardial infarction (STEMI) and multivessel disease has not been well established. In the present cohort study, we sought to examine the safety and efficacy of inhospital staged PCI for patients with STEMI and multivessel disease. We identified all patients with STEMI referred for primary PCI who were found to have multivessel disease (stenosis ≥50% in nonculprit vessel) and compared clinical outcomes in relation to the management strategy, staged versus culprit-only PCI, for nonculprit vessel disease. The primary outcome was mortality at 180 days, and secondary outcomes included mortality during the index hospitalization and at 30 days, myocardial infarction, stent thrombosis, stroke, and bleeding. Of the 1,038 patients with STEMI meeting inclusion criteria, 259 (25%) underwent staged PCI and 779 (75%) culprit-only PCI during the index admission. Mortality at 180 days was 0.8% in patients with staged PCI and 5.0% in patients with culprit-only PCI (p = 0.003). The association between staged PCI and reduced mortality persisted after adjusting for baseline differences in patient characteristics and angiographic variables between the 2 cohorts (odds ratio 0.2, 95% confidence interval 0.04 to 0.77, p = 0.02). The rates of inhospital reinfarction in the staged and culprit-only PCI cohorts were 0.8% versus 1.3% (p = 0.50), respectively, stent thrombosis 0.8% versus 1.3% (p = 0.50), and stroke 0.4% versus 1.3% (p = 0.31). There were no inhospital adverse events related to acute occlusion of a nonculprit vessel in either cohort. Staged PCI during index admission is a safe and effective revascularization strategy for patients with STEMI and multivessel disease.

Elevated lipoprotein-associated phospholipase A2 is associated with progression of nonculprit lesions after percutaneous coronary intervention

Lipoprotein-associated phospholipase A2 (Lp-PLA2) is an enzyme that hydrolyzes oxidized phospholipids to generate bioactive proatherogenic products. Nonculprit lesions have been assumed to contribute to the pathogenesis of recurrent acute coronary syndrome (ACS). The role of LP-PLA2 in the progression of nonculprit coronary lesions after successful percutaneous coronary intervention (PCI) remains unclear. Our study included 123 patients with ACS who underwent initial PCI and a long-term follow-up (mean interval, one year) with coronary angiography. Among them, 19 patients were diagnosed as the progression of nonculprit lesions, based on the presence of at least one of the following factors: (1) ≥ 10% reduction in the diameter of a preexisting ≥ 50% stenosis; (2) ≥ 30% reduction in the diameter of a < 50% stenosis; and (3) early-onset stenosis with ≥ 30% reduction in the diameter of a segment that was normal on the primary angiogram. Blood sampling was drawn from all patients at 12-14 hours after PCI. The ACS patients with progression had higher total cholesterol (4.47 ± 1.02 mmol/L vs. 3.59 ± 0.57 mmol/L, P < 0.05), higher levels of Lp-PLA2 activity (14.39 ± 6.13 nmol/min/ml vs. 8.86 ± 3.14 nmol/min/ml, P < 0.001) and a higher proportion of multi-vessel disease than those without progression. Multivariate logistic regression analysis showed that Lp-PLA2 activity (β = 0.024, P = 0.005) was an independent predictor for rapid progression of nonculprit coronary lesions. In conclusion, elevated Lp-PLA2 activity is associated with rapid progression of nonculprit coronary lesions in ACS patients who underwent PCI.

Fractional flow reserve for the assessment of nonculprit coronary artery stenoses in patients with acute myocardial infarction

OBJECTIVES

We investigated the reliability of fractional flow reserve (FFR) of nonculprit coronary stenoses during percutaneous coronary intervention (PCI) in acute myocardial infarction.

BACKGROUND

Assessing the hemodynamic severity of the nonculprit coronary artery stenoses at the acute phase of a myocardial infarction could improve risk stratification and shorten the diagnostic work-up.

METHODS

One hundred one patients undergoing PCI for an acute myocardial infarction (n = 75 with ST-segment elevation myocardial infarction [STEMI], and n = 26 with non-ST-segment elevation myocardial infarction) were prospectively recruited. The FFR measurements in 112 nonculprit stenoses were obtained immediately after PCI of the culprit stenosis and were repeated 35 ± 4 days later. In addition, left ventricular ejection fraction, quantitative coronary angiographic measurements of the nonculprit stenoses, Thrombolysis In Myocardial Infarction (TIMI) flow, corrected TIMI frame count (cTFC), and the index of microcirculatory resistance (n = 14) of the nonculprit vessels were assessed in the acute phase and at control angiogram.

RESULTS

The FFR value of the nonculprit stenoses did not change between the acute and follow-up (0.77 ± 0.13 vs. 0.77 ± 0.13, respectively, p = NS). In only 2 patients, the FFR value was higher than 0.8 at the acute phase and lower than 0.75 at follow-up. The TIMI flow, cTFC, percentage diameter stenosis, minimum lumen diameter, and index of microcirculatory resistance did not change. Left ventricular ejection fraction increased significantly in patients with STEMI (from 54 ± 13% to 57 ± 13%, p = 0.03).

CONCLUSIONS

During the acute phase of acute coronary syndromes, the severity of nonculprit coronary artery stenoses can reliably be assessed by FFR. This allows a decision about the need for additional revascularization and might contribute to a better risk stratification.