Rationale and design of the MULTISTARS AMI Trial: A randomized comparison of immediate versus staged complete revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease

Updated Strategies in Non-Culprit Stenosis Management of Multivessel Coronary Disease-A Contemporary Review

The prevalence of multivessel coronary artery disease (CAD) in acute coronary syndrome (ACS) patients underscores the need for optimal revascularization strategies. The ongoing debate surrounding percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), hybrid interventions, or medical-only management adds complexity to decision-making, particularly in specific angiographic scenarios. The article critically reviews existing literature, providing evidence-based perspectives on non-culprit lesion revascularization in ACS. Emphasis is placed on nuances such as the selection of revascularization methods, optimal timing for interventions, and the importance of achieving completeness in revascularization. The debate between culprit-only revascularization and complete revascularization is explored in detail, focusing on ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI), including patients with cardiogenic shock. Myocardial revascularization guidelines and recent clinical trials support complete revascularization strategies, either during the index primary PCI or within a short timeframe following the culprit lesion PCI (in both STEMI and NSTEMI). The article also addresses the complexities of decision-making in NSTEMI patients with multivessel CAD, advocating for immediate multivessel PCI unless complex coronary lesions require a staged revascularization approach. Finally, the article provided contemporary data on chronic total occlusion revascularization in ACS patients, highlighting the prognostic impact. In conclusion, the article addresses the evolving challenges of managing multivessel CAD in ACS patients, enhancing thoughtful integration into the clinical practice of recent data. We provided evidence-based, individualized approaches to optimize short- and long-term outcomes. The ongoing refinement of clinical and interventional strategies for non-culprit lesion management remains dynamic, necessitating careful consideration of patient characteristics, coronary stenosis complexity, and clinical context.

Timing of Complete Revascularization with Multivessel PCI for Myocardial Infarction

BACKGROUND

In patients with ST-segment elevation myocardial infarction (STEMI) with multivessel coronary artery disease, the time at which complete revascularization of nonculprit lesions should be performed remains unknown.

METHODS

We performed an international, open-label, randomized, noninferiority trial at 37 sites in Europe. Patients in a hemodynamically stable condition who had STEMI and multivessel coronary artery disease were randomly assigned to undergo immediate multivessel percutaneous coronary intervention (PCI; immediate group) or PCI of the culprit lesion followed by staged multivessel PCI of nonculprit lesions within 19 to 45 days after the index procedure (staged group). The primary end point was a composite of death from any cause, nonfatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure at 1 year after randomization. The percentages of patients with a primary or secondary end-point event are provided as Kaplan-Meier estimates at 6 months and at 1 year.

RESULTS

We assigned 418 patients to undergo immediate multivessel PCI and 422 to undergo staged multivessel PCI. A primary end-point event occurred in 35 patients (8.5%) in the immediate group as compared with 68 patients (16.3%) in the staged group (risk ratio, 0.52; 95% confidence interval, 0.38 to 0.72; P<0.001 for noninferiority and P<0.001 for superiority). Nonfatal myocardial infarction and unplanned ischemia-driven revascularization occurred in 8 patients (2.0%) and 17 patients (4.1%), respectively, in the immediate group and in 22 patients (5.3%) and 39 patients (9.3%), respectively, in the staged group. The risk of death from any cause, the risk of stroke, and the risk of hospitalization for heart failure appeared to be similar in the two groups. A total of 104 patients in the immediate group and 145 patients in the staged group had a serious adverse event.

CONCLUSIONS

Among patients in hemodynamically stable condition with STEMI and multivessel coronary artery disease, immediate multivessel PCI was noninferior to staged multivessel PCI with respect to the risk of death from any cause, nonfatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure at 1 year. (Supported by Boston Scientific; MULTISTARS AMI ClinicalTrials.gov number, NCT03135275.).

Immediate versus staged revascularisation of non-culprit arteries in patients with acute coronary syndrome: a systematic review and meta-analysis

Although there is robust evidence that revascularisation of non-culprit vessels should be pursued in patients presenting with an acute coronary syndrome (ACS) and multivessel coronary artery disease (MVD), the optimal timing of complete revascularisation remains disputed. In this systematic review and meta-analysis our results suggest that outcomes are comparable for immediate and staged complete revascularisation in patients with ACS and MVD. However, evidence from randomised controlled trials remains scarce and cautious interpretation of these results is recommended. More non-biased evidence is necessary to aid future decision making on the optimal timing of complete revascularisation.

The optimal timing for non-culprit percutaneous coronary intervention in patients with multivessel coronary artery disease: A pairwise and network meta-analysis of randomized trials

Background and aims

Recently, several randomized trials have shown that patients with multivessel disease (MVD) often pursue complete revascularization during percutaneous coronary intervention (PCI) to improve their prognosis. However, the optimal time for the non-culprit artery has been controversial. This study aimed to determine the optimal strategy for revascularization in ST-segment elevation myocardial infarction (STEMI) patients with multivessel coronary artery disease (CAD).

Methods

Randomized controlled trials (RCTs) comparing three revascularization strategies [i.e., complete revascularization at the index procedure (CR), complete revascularization as a staged procedure (SR), or culprit-only revascularization (COR)] in STEMI patients with multivessel coronary artery disease were included. We performed both pairwise and network meta-analyses. Network meta-analysis was performed using mixed treatment comparison models.

Results

17 trials with 8568 patients were included. In the network meta-analysis, the most interesting finding was that staged revascularization increased the risk of major adverse cardiac events (MACE) compared with complete revascularization at the index procedure [odds ratio (OR): 1.93; 95% confidence interval (CI): 1.07–3.49]. In the pairwise meta-analysis, complete revascularization reduced the incidence of MACE [risk ratio (RR): 0.62, 95% CI: 0.48–0.79, p &lt; 0.001], mainly because it reduced the probability of unplanned repeat revascularization (RR: 0.49, 95% CI: 0.33–0.75, p = 0.001). There were no significant differences in all-cause mortality, cardiac mortality, or nonfatal re-myocardial infarction (MI).

Conclusion

Our analysis suggests that complete revascularization should be performed in STEMI patients with multivessel coronary artery disease, and complete revascularization at the index procedure is superior to staged revascularization in reducing the risk of MACE events.

Impact of Stress Hyperglycemia on the Timing of Complete Revascularization in Non-diabetes Patients with ST Elevation Myocardial Infarction and Multivessel Disease

Background: Stress hyperglycemia (SHG) is related to an increased risk of mortality in diabetic patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). However, data are limited in non-diabetic patients especially in patients with multivessel disease (MVD). Methods and Results: In this retrospective study, 742 non-diabetic patients with STEMI and MVD were divided into SHG group and non-SHG group. The overall incidence of SHG was 24.9%. The incidence of no-reflow (NR) phenomenon (18.4% vs 11.8%; P = .024) and in-hospital mortality (1.6% vs .2%; P = .020) in SHG group were significantly higher than those in non-SHG group. SHG was associated with 30-day MACE (hazard ratio, 4.265; 95% confidence interval (CI), 1.354-13.439; P = .013), but not 1-year. Multivariate logistic analysis showed that SHG (odds ratio: 1.691, 95% CI: 1.072-2.667, P = .024) was an independent predictor of NR. If complete revascularization (CR) was performed during PPCI, the incidence of NR would be significantly higher. Conclusion: In non-diabetic patients with STEMI and MVD, SHG is associated with increased SF-NR and short-term adverse events, and CR during PPCI further increases the risk of NR.

A comparison of long-term clinical outcomes between percutaneous coronary intervention (PCI) and medical therapy in patients with chronic total occlusion in noninfarct-related artery after PCI of acute myocardial infarction

BACKGROUND

Chronic total occlusion (CTO) in a noninfarct-related artery (IRA) is one of the risk factors for mortality after acute myocardial infarction (AMI). However, there are limited data comparing the long-term outcomes of patients undergoing percutaneous coronary intervention (PCI) with patients having medical therapy (MT) in CTO lesion after AMI PCI.

METHODS

We retrospectively enrolled 330 patients (successful CTO PCI in 166 patients, failed CTO PCI in 32 patients, MT in 132 patients) with non-IRA CTO from a total of 4372 patients who underwent PCI after AMI in our center. Propensity score matching (PSM) was used to adjust for baseline differences.

RESULTS

The primary analysis is based on the intention-to-treat population. During a median follow-up period of 946 days, patients in the PCI group (n = 198) had significantly higher cardiac death-free survival (96.6% vs. 82.8%, p = .004) compared with patients in MT group (n = 132). However, no significant difference in the occurrence of cardiac death was observed after PSM. The analysis based on the per-protocol population demonstrated significantly higher cardiac death-free survival in the successful CTO PCI group (n = 166) compared with the occluded CTO group (n = 164) both before and after PSM. In subgroup analysis, successful CTO PCI was associated with less cardiac death in patients over 65 years old, with LVEF < 50%, left anterior descending (LAD) IRA, and non-LAD CTO lesion compared with occluded CTO group.

CONCLUSIONS

Patients undergoing successful revascularization of non-IRA CTO after AMI might have a better long-term prognosis. Moreover, patients with LVEF < 50% may benefit from successful non-IRA CTO PCI after AMI.

Percutaneous Coronary Revascularization: JACC Historical Breakthroughs in Perspective

Over the last 4 decades, percutaneous coronary intervention has evolved dramatically and is now an acceptable treatment option for patients with advanced coronary artery disease. However, trialists have struggled to establish the respective roles for percutaneous coronary intervention and coronary artery bypass graft surgery, especially in patients with multivessel disease and unprotected left-main stem coronary artery disease. Several pivotal trials and meta-analyses comparing these 2 revascularization strategies have enabled the relative merits of each technique to be established with regard to the type of ischemic syndrome, the coronary anatomy, and the patient's overall comorbidity. Precision medicine with individualized prognosis is emerging as an important method of selecting treatment. However, the never-ending advancement of technology, in conjunction with the emergence of novel pharmacological agents, will in the future continue to force us to reconsider the evolving question: "Which treatment strategy is better and for which patient?"