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Akbari T, Al-Lamee R. Percutaneous coronary intervention in multi-vessel disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 44:80-91. [DOI: 10.1016/j.carrev.2022.06.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 01/09/2023]
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Cadore JC, Furtado MV, Tumelero R, Tognon A, Krepsky AM, Cadore D, Ruschel KB, Bedin JC, Conte T, Polanczyk CA. Complete Revascularization Versus Treatment of the Culprit Artery Only in ST Elevation Myocardial Infarction: A Multicenter Registry. Arq Bras Cardiol 2020; 115:229-237. [PMID: 32876190 PMCID: PMC8384275 DOI: 10.36660/abc.20180346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 08/18/2019] [Indexed: 01/24/2023] Open
Abstract
Fundamento São restritos os dados sobre o manejo e o prognóstico dos pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCSST) com acometimento multiarterial no Brasil, o que mostra a necessidade de investigar as estratégias de revascularização disponíveis. Objetivo Avaliar os desfechos relacionados à revascularização completa em comparação com o tratamento da artéria culpada em pacientes multiarteriais com IAMCSST. Métodos Foi realizada um estudo de coorte prospectiva em dois centros de hemodinâmica do Sul do Brasil, com seguimento de 1 ano após a intervenção índice. O desfecho primário foi composto de óbito cardiovascular, reinfarto ou angina recorrente e secundários acidente vascular encefálico, parada cardiorrespiratória não fatal, sangramento maior ou necessidade de reintervenção. A probabilidade de ocorrência de desfechos foi comparada entre os grupos através de regressão logística binária. Considerou-se como estatisticamente significativo o valor de probabilidade < 0,05. Resultados Participaram 85 pacientes, com média de idade de 62±12 anos, sendo 61 (71,8%) do sexo masculino. Cinquenta e oito (68,2%) pacientes receberam a estratégia de revascularização completa e 27 (31,8%), a de revascularização incompleta. A chance de ocorrência tanto do desfecho primário quanto do secundário foi significativamente maior entre os indivíduos tratados com revascularização incompleta quando comparados com os tratados com estratégia completa [razão de chances (OR) 5,1, intervalo de confiança de 95% (IC95%) 1,6-16,1 vs. OR 5,2, IC95% 1,2-22,9, respectivamente], assim como os óbitos cardiovasculares (OR 6,4, IC95% 1,2-35,3). Conclusão Dados deste registro regional, de dois centros do Sul do Brasil, demonstram que a estratégia de revascularização completa esteve associada à redução significativa dos desfechos primário e secundário no seguimento de 1 ano quando comparada à estratégia de revascularização incompleta. (Arq Bras Cardiol. 2020; 115(2):229-237)
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Affiliation(s)
- Julia Cremona Cadore
- Universidade Federal do Rio Grande do Sul - PPG Ciências Cardiovasculares: Cardiologia, Porto Alegre, RS - Brasil
| | - Mariana Vargas Furtado
- Hospital de Clínicas de Porto Alegre - Instituto de Avaliação de Tecnologia em Saúde, Porto Alegre, RS - Brasil
| | | | | | - Ana Maria Krepsky
- Universidade Federal do Rio Grande do Sul - PPG Ciências Cardiovasculares: Cardiologia, Porto Alegre, RS - Brasil
| | - Denis Cadore
- Universidade de Passo Fundo, Passo Fundo, RS - Brasil
| | - Karen Brasil Ruschel
- Hospital de Clínicas de Porto Alegre - Instituto de Avaliação de Tecnologia em Saúde, Porto Alegre, RS - Brasil
| | - Julia Caldas Bedin
- Universidade Federal do Rio Grande do Sul - Faculdade de Medicina, Porto Alegre, RS - Brasil
| | - Thais Conte
- Universidade Federal do Rio Grande do Sul - Faculdade de Medicina, Porto Alegre, RS - Brasil
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Rathod KS, Koganti S, Jain AK, Astroulakis Z, Lim P, Rakhit R, Kalra SS, Dalby MC, O'Mahony C, Malik IS, Knight CJ, Mathur A, Redwood S, Sirker A, MacCarthy PA, Smith EJ, Wragg A, Jones DA. Complete Versus Culprit-Only Lesion Intervention in Patients With Acute Coronary Syndromes. J Am Coll Cardiol 2019; 72:1989-1999. [PMID: 30336821 DOI: 10.1016/j.jacc.2018.07.089] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 06/29/2018] [Accepted: 07/30/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND A large proportion of patients presenting with non-ST-segment elevation myocardial infarction (NSTEMI) present with multivessel disease (MVD). There is uncertainty in the role of complete coronary revascularization in this group of patients. OBJECTIVES The aim of this study was to investigate the outcomes of complete revascularization compared with culprit vessel-only intervention in a large contemporary cohort of patients undergoing percutaneous coronary intervention (PCI) for NSTEMI. METHODS The authors undertook an observational cohort study of 37,491 NSTEMI patients treated between 2005 and 2015 at the 8 heart attack centers in London. Clinical details were recorded at the time of the procedure into local databases using the British Cardiac Intervention Society (BCIS) PCI dataset. A total of 21,857 patients (58.3%) presented with NSTEMI and MVD. Primary outcome was all-cause mortality at a median follow-up of 4.1 years (interquartile range: 2.2 to 5.8 years). RESULTS A total of 11,737 (53.7%) patients underwent single-stage complete revascularization during PCI for NSTEMI, rates that significantly increased during the study period (p = 0.006). Those patients undergoing complete revascularization were older and more likely to be male, diabetic, have renal disease and a history of previous myocardial infarction/revascularization compared with the culprit-only revascularization group. Although crude, in-hospital major adverse cardiac event rates were similar (5.2% vs. 4.8%; p = 0.462) between the 2 groups. Kaplan-Meier analysis demonstrated significant differences in mortality rates between the 2 groups (22.5% complete revascularization vs. 25.9% culprit vessel intervention; p = 0.0005) during the follow-up period. After multivariate Cox analysis (hazard ratio: 0.90; 95% confidence interval: 0.85 to 0.97) and the use of propensity matching (hazard ratio: 0.89; 95% confidence interval: 0.76 to 0.98) complete revascularization was associated with reduced mortality. CONCLUSIONS In NSTEMI patients with MVD, despite higher initial (in-hospital) mortality rates, single-stage complete coronary revascularization appears to be superior to culprit-only vessel PCI in terms of long-term mortality rates. This supports the need for further randomized study to confirm these findings.
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Affiliation(s)
| | | | - Ajay K Jain
- Barts Health NHS Trust, London, United Kingdom
| | - Zoe Astroulakis
- St. George's Healthcare NHS Foundation Trust, St. George's Hospital, London, United Kingdom
| | - Pitt Lim
- St. George's Healthcare NHS Foundation Trust, St. George's Hospital, London, United Kingdom
| | - Roby Rakhit
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | | | - Miles C Dalby
- Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, Middlesex, London, United Kingdom
| | | | - Iqbal S Malik
- Imperial College Healthcare NHS Foundation Trust, Hammersmith Hospital, London, United Kingdom
| | | | | | - Simon Redwood
- St. Thomas' NHS Foundation Trust, Guys & St. Thomas Hospital, London, United Kingdom
| | | | - Philip A MacCarthy
- Kings College Hospital, King's College Hospital NHS Foundation Trust, Denmark Hill, London, United Kingdom
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Fatima U, Khan SU, Akanbi O, Girotra S, Opoku-Asare I. Network Meta-Analysis of Percutaneous Intervention-Based Revascularization Strategies for ST-Elevation Myocardial Infarction and Concomitant Multi-Vessel Disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 20:603-611. [PMID: 30196030 PMCID: PMC6426681 DOI: 10.1016/j.carrev.2018.08.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/23/2018] [Accepted: 08/23/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND In patients with ST elevation myocardial infarction (STEMI) and concomitant multi-vessel disease (MVD), primary percutaneous coronary intervention (PCI) of the culprit vessel is the preferred reperfusion strategy. However, optimum timing of revascularization for non-culprit artery is unclear. In this Bayesian network meta-analysis (NMA), we compared different PCI-based revascularization strategies in STEMI patients with MVD. METHODS 11 randomized controlled trials (RCTs) were selected using MEDLINE, EMBASE and CENTRAL (Inception to September 2017). For all outcomes, median estimate of odds ratio from posterior distribution with corresponding 95% credible interval was calculated. The Surface under the Cumulative Ranking Curve (SUCRA) metric was used to estimate the relative ranking probability of each intervention. Sensitivity analysis was conducted by excluding the RCTs in which the staged intervention was performed after two weeks of the index procedure or post discharge. RESULTS In this NMA of 3172 patients, CR-I (instant complete revascularization) was associated with 40% relative risk reduction in all-cause mortality compared with IRA (infarct related artery) [0.60 (0.31-0.89)]. CR-I was superior to CR-S (staged complete revascularization) [0.42 (0.22-0.70)] and IRA [0.50(0.29-0.72)] in reducing the risk of re- infarction. Both CR-I and CR-S significantly reduced the risk of repeat revascularization compared to IRA, whereas the risk of CIN (contrast induced nephropathy) and major bleeding was similar across all interventions. Sensitivity analysis showed, that CR-I was a better strategy compared with CR-S [0.34 (0.12-0.74)] and IRA (0.60 [0.36-0.97]) in reducing all-cause mortality. CONCLUSIONS In this NMA, CR-I was associated with reduction in all-cause mortality and re- infarction compared with IRA.
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Affiliation(s)
- Urooj Fatima
- Howard University Hospital, United States of America.
| | - Safi U Khan
- West Virginia University, United States of America
| | | | - Saket Girotra
- University of Iowa Hospitals and Clinics, United States of America
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Metaanalysis of Multivessel vs Culprit Artery Only Percutaneous Coronary Intervention in ST Elevation Myocardial Infarction. Ochsner J 2019; 19:107-115. [PMID: 31258422 DOI: 10.31486/toj.18.0033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: Primary percutaneous coronary intervention (PCI) is the most frequently used treatment modality for patients presenting with ST elevation myocardial infarction (STEMI). Current professional society guidelines recommend culprit artery only PCI. Recent evidence suggests the potential benefit of multivessel PCI among patients with STEMI that is not complicated by cardiogenic shock. Methods: We systematically searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials for clinical studies of patients with STEMI, not complicated by cardiogenic shock, who underwent primary PCI between January 1966 and January 2018. We evaluated all-cause and cardiovascular mortality, reinfarction, and repeat revascularization among patients randomized to a multivessel PCI strategy compared to a culprit artery only PCI strategy. Results: Four randomized clinical trials with a total of 1,044 patients met the inclusion criteria. Five hundred and sixty-six patients underwent multivessel PCI, and 478 patients underwent culprit artery only PCI. Multivessel PCI reduced all the studied endpoints: total death, cardiac death, reinfarction, and repeat revascularization (all P values <0.05). Conclusion: To our knowledge, this is the largest metaanalysis of randomized controlled trials studying multivessel PCI vs culprit artery only PCI in STEMI patients without shock, among whom lesion severity was graded by angiography alone. We found that compared to culprit artery only PCI, the multivessel PCI strategy was beneficial in reducing all-cause and cardiovascular mortality, reinfarction, and the need for repeat revascularization.
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Angiography-guided Multivessel Percutaneous Coronary Intervention Versus Ischemia-guided Percutaneous Coronary Intervention Versus Medical Therapy in the Management of Significant Disease in Non-Infarct-related Arteries in ST-Elevation Myocardial Infarction Patients With Multivessel Coronary Disease. Crit Pathw Cardiol 2019; 17:77-82. [PMID: 29768315 DOI: 10.1097/hpc.0000000000000144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND In ST-elevation myocardial infarction (STEMI) patients with multivessel (MV) disease, after primary percutaneous coronary intervention (PCI), emerging evidence suggests that significant disease in non-infarct-related coronary arteries (IRAs) should be routinely stented. Whether this procedure should be guided by angiography alone or ischemia testing is unclear. METHODS All STEMI patients treated with primary PCI between January 1, 2005, and December 31, 2012, at a tertiary cardiology center were reviewed retrospectively. Inclusion criterion is patients with at least 70% stenosis in non-IRAs. There were 3 treatment groups: (1) angiography-guided MV-PCI, (2) ischemia-guided PCI, and (3) medical therapy. Primary endpoint is all-cause mortality, and secondary end point is major adverse cardiovascular events (MACE), including death, acute coronary syndrome, revascularization, or stent thrombosis. Event-free survivals were compared using multivariate Cox proportional-hazards analysis. A propensity score-adjusted analysis was performed. RESULTS Four hundred forty-seven STEMI patients had >70% stenosis in non-IRAs. For all-cause mortality, the 3 strategies did not differ. For MACE, ischemia-guided PCI was associated with the lowest MACE rate, followed by angiography-guided PCI and medical therapy, which was associated with the highest MACE rate, driven by death and myocardial infarction. Hazard ratios (HRs) for MACE: angiography-guided MV-PCI versus ischemia-guided MV-PCI: HR = 2.23 [95% confidence interval (CI), 1.11-4.48; P = 0.023]; medical therapy versus angiography-guided MV-PCI: HR = 1.58 (95% CI, 0.99-2.63; P = 0.062); medical therapy versus ischemia-guided MV-PCI: HR = 1.72 (95% CI, 1.08-2.74; P = 0.022). Propensity score-adjusted analysis yielded similar results. CONCLUSIONS After primary PCI, complete revascularization in STEMI multivessel disease is associated with lower MACE rates than medical therapy. However, ischemia-testing-guided rather than angiography-guided revascularization was associated with the lowest MACE. This study provides preliminary data and hypotheses for future randomized controlled studies.
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Tsai MS, Sung CW, Chen WJ, Chuang PY, Wang CH, Wu YW, Chang WT, Chen WT, Huang CH. Stenosis and revascularization of the coronary artery are associated with outcomes in presumed cardiogenic arrest survivors: A multi-center retrospective cohort study. Resuscitation 2019; 137:52-60. [PMID: 30772425 DOI: 10.1016/j.resuscitation.2019.01.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 01/18/2019] [Accepted: 01/31/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND The emergent coronary angiography (CAG) is associated with better outcomes in CA survivors. However, the impact of severity and revascularization of coronary artery stenosis on outcomes in cardiac arrest (CA) survivors remains unclear. METHODS A total of 273 non-traumatic adult CA survivors who underwent emergent CAG from January 2011 to July 2017 were retrospectively recruited. The stenosis and non-revascularization of an individual coronary artery ≥70% were defined as significant in any of the major coronary arteries based on an operator visual estimate. RESULTS There were 201 patients (73.63%) had ≧1 significant coronary artery stenosis and 58 patients (21.25%) with ≧1 non-revascularized coronary artery. The increased number of stenosed coronary artery was associated with an increased risk for in-hospital mortality [1-vessel: adjusted hazard ration (HR) 2.27, 95% confidence interval (CI) = 1.43-4.04, p = 0.021; 2-vessel: adjusted HR 5.49, 95% CI=2.17-13.89, p < 0.001; 3-vessel: adjusted HR 11.05, 95% CI=4.20-29.04, p < 0.001)] and poor neurological recovery (cerebral performance category = 3-5) [(1-vessel: adjusted odds ration (OR) 1.66, 95% CI 0.67-4.15, =0.275; 2-vessel: adjusted OR 1.81, 95% CI 1.05-3.97, p = 0.045; 3-vessel: adjusted OR 3.19, 95% CI 1.25-8.15, p = 0.001)], which was positively correlated with the number of vessels. The incomplete revascularization were also associated with increased in-hospital mortality and poor neurological function in patients with ≧1vessel stenosis. CONCLUSION The severity and incomplete revascularization of coronary artery stenosis were associated with increased in-hospital mortality and poor neurological recovery in patients with presumed cardiogenic arrest.
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Affiliation(s)
- Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Chih-Wei Sung
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Wen-Jone Chen
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan; Department of Internal Medicine (Cardiology division), National Taiwan University Medical College and Hospital, Taipei, Taiwan.
| | - Po-Ya Chuang
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
| | - Chih-Hung Wang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Yen-Wen Wu
- Department of Nuclear Medicine, Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Wei-Tien Chang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Wei-Ting Chen
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan.
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Gibler WB, Racadio JM, Hirsch AL, Roat TW. Continuum of Care for Acute Coronary Syndrome: Optimizing Treatment for ST-Elevation Myocardial Infarction and Non-St-Elevation Acute Coronary Syndrome. Crit Pathw Cardiol 2018; 17:114-138. [PMID: 30044253 PMCID: PMC6072372 DOI: 10.1097/hpc.0000000000000151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- W Brian Gibler
- President, EMCREG-International, Professor of Emergency Medicine, Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
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Complete Versus Culprit-Only Revascularization in STEMI: a Contemporary Review. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:41. [PMID: 29627944 DOI: 10.1007/s11936-018-0636-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW In ST-segment elevation myocardial infarction, urgent revascularization of the culprit coronary vessel and restoration of coronary flow is the goal of the initial management. However, obstructive non-culprit disease is frequently concomitantly found during initial angiography and portends a poor prognosis. Management of non-culprit lesions in ST-segment elevation myocardial infarction (STEMI) has been the subject of extensive debate. This review will examine the currently available evidence, with a specific focus on randomized clinical trials performed to date. RECENT FINDINGS Although early observational data suggested better outcomes with culprit-only revascularization, more recent data from several randomized trials have suggested improved outcomes with complete multivessel revascularization, either during the index PCI procedure or as a staged procedure. Data from recent randomized controlled trials have suggested the superiority of complete or multivessel revascularization and have subsequently led to changes to the most recent iterations of STEMI guidelines. However, the optimal management and timing of revascularization of non-culprit lesions in STEMI remain controversial.
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Osório APS, Quadros ASD, Vieira JLDC, Portal VL. Percutaneous Intervention in ST-Elevation Myocardial Infarction: Culprit-only or Complete Revascularization? Arq Bras Cardiol 2017; 109:599-605. [PMID: 29185617 PMCID: PMC5783441 DOI: 10.5935/abc.20170174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Accepted: 07/05/2017] [Indexed: 01/25/2023] Open
Abstract
The best approach of multivessel coronary artery disease in the context of acute myocardial infarction with ST segment elevation and primary percutaneous coronary intervention is one of the main reasons for controversy in cardiology. Although the main global guidelines do not recommend routine complete revascularization in these patients, recent randomized clinical trials have demonstrated benefit of this approach in reducing cardiovascular outcomes. For this reason, an adequate review of this evidence is essential in order to establish scientifically based strategy and achieve better outcomes for these patients who present with acute myocardial infarction. This review aims to present objectively the most recent evidence available on this topic.
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Affiliation(s)
- Ana Paula Susin Osório
- Instituto de Cardiologia/Fundação Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | | | | | - Vera Lucia Portal
- Instituto de Cardiologia/Fundação Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
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Patel S, Bailey SR. Revascularization Strategies in STEMI with Multivessel Disease: Deciding on Culprit Versus Complete-Ad Hoc or Staged. Curr Cardiol Rep 2017; 19:93. [PMID: 28840487 DOI: 10.1007/s11886-017-0906-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW This review will address the clinical conundrum of those who may derive clinical benefit from complete revascularization of coronary stenosis that are discovered at the time of ST segment elevation myocardial infarction (STEMI). The decision to revascularize additional vessels with angiographic stenosis beyond the culprit lesion remains controversial, as does the timing of revascularization. RECENT FINDINGS STEMI patients represent a high-risk patient population that have up to a 50% prevalence of multivessel disease. Multivessel disease represents an important risk factor for short- and long-term morbidity and mortality. Potential benefits of multivessel PCI for STEMI might include reduced short- and long-term mortality, revascularization, reduced resource utilization, and costs. Which population will benefit and what the optimal timing of revascularization in the peri-MI period remains controversial. Consideration of multivessel revascularization in the setting of STEMI may occur in up to one half of STEMI patients. Evaluation of the comorbidities including diabetes, extent of myocardium at risk, lesion complexity, ventricular function, and risk factors for complications such as contrast induced nephropathy which is important in determining the appropriate care pathway.
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Affiliation(s)
- Shalin Patel
- From the Janey Briscoe Center of Excellence for Cardiovascular Research, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78232, USA
| | - Steven R Bailey
- From the Janey Briscoe Center of Excellence for Cardiovascular Research, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78232, USA.
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Vogel B, Mehta SR, Mehran R. Reperfusion strategies in acute myocardial infarction and multivessel disease. Nat Rev Cardiol 2017; 14:665-678. [DOI: 10.1038/nrcardio.2017.88] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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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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Cubero-Gallego H, Romaguera R, Ariza-Sole A, Gómez-Hospital JA, Cequier A. Revascularization strategies in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease: urgent or staged? Cardiovasc Diagn Ther 2017; 7:S82-S85. [PMID: 28748154 DOI: 10.21037/cdt.2017.01.15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Héctor Cubero-Gallego
- Heart Diseases Institute, Hospital de Bellvitge - IDIBELL, University of Barcelona, Barcelona, Spain
| | - Rafael Romaguera
- Heart Diseases Institute, Hospital de Bellvitge - IDIBELL, University of Barcelona, Barcelona, Spain
| | - Albert Ariza-Sole
- Heart Diseases Institute, Hospital de Bellvitge - IDIBELL, University of Barcelona, Barcelona, Spain
| | | | - Angel Cequier
- Heart Diseases Institute, Hospital de Bellvitge - IDIBELL, University of Barcelona, Barcelona, Spain
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Gaffar R, Habib B, Filion KB, Reynier P, Eisenberg MJ. Optimal Timing of Complete Revascularization in Acute Coronary Syndrome: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2017; 6:JAHA.116.005381. [PMID: 28396570 PMCID: PMC5533029 DOI: 10.1161/jaha.116.005381] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Studies have suggested that complete revascularization is superior to culprit‐only revascularization for the treatment of enzyme‐positive acute coronary syndrome. However, the optimal timing of complete revascularization remains unclear. We conducted a systematic review and meta‐analysis of randomized controlled trials comparing single‐stage complete revascularization with multistage percutaneous coronary intervention in patients with ST‐segment elevation myocardial infarction or non–ST‐segment elevation myocardial infarction with multivessel disease. Methods and Results We systematically searched the Cochrane Central Register of Controlled Trials, Embase, PubMed, and MEDLINE for randomized controlled trials comparing single‐stage complete revascularization with multistage revascularization in patients with enzyme‐positive acute coronary syndrome. The primary outcome was the incidence of major adverse cardiovascular events at longest follow‐up. Data were pooled using DerSimonian and Laird random‐effects models. Four randomized controlled trials (n=838) were included in our meta‐analysis. The risk of unplanned repeat revascularization at longest follow‐up was significantly lower in patients randomized to single‐stage complete revascularization (risk ratio, 0.68; 95% CI, 0.47–0.99). Results also suggest a trend towards lower risks of major adverse cardiovascular events for patients randomized to single‐stage revascularization at 6 months (risk ratio, 0.67; 95% CI, 0.40–1.11) and at longest follow‐up (risk ratio, 0.79; 95% CI, 0.52–1.20). Risks of mortality and recurrent myocardial infarction at longest follow‐up were also lower with single‐stage revascularization, but 95% CIs were wide and included unity. Conclusions Our results suggest that single‐stage complete revascularization is safe. There also appears to be a trend towards lower long‐term risks of mortality and major adverse cardiovascular events; however, additional randomized controlled trials are required to confirm the potential benefits of single‐stage multivessel percutaneous coronary intervention.
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Affiliation(s)
- Rouan Gaffar
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Bettina Habib
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Kristian B Filion
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Departments of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Pauline Reynier
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Mark J Eisenberg
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada .,Division of Cardiology, Jewish General Hospital, Montreal, Quebec, Canada.,Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Departments of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
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Marino M, Crimi G, Leonardi S, Ferlini M, Repetto A, Camporotondo R, Demarchi A, De Pascali I, Falcinella F, Oltrona Visconti L, De Servi S, Ferrario M, De Ferrari GM, Gnecchi M. Comparison of Outcomes of Staged Complete Revascularization Versus Culprit Lesion-Only Revascularization for ST-Elevation Myocardial Infarction and Multivessel Coronary Artery Disease. Am J Cardiol 2017; 119:508-514. [PMID: 28007297 DOI: 10.1016/j.amjcard.2016.10.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 10/31/2016] [Accepted: 10/31/2016] [Indexed: 01/03/2023]
Abstract
The management of noninfarct-related arteries in patients with ST-elevation myocardial infarction (STEMI) and multivessel coronary disease (MVD) is still debated. We evaluated the prognostic impact of staged complete revascularization with percutaneous coronary intervention (PCI) in STEMI patients with MVD admitted to our hospital from 2005 to 2013. Patients undergoing staged complete revascularization (n = 300) were compared with 1:1 propensity score-matched patients with culprit lesion-only treatment (n = 300). We considered a composite primary end point of all-cause death, myocardial infarction, and urgent PCI. Secondary end points included components of the primary, cardiovascular death, any PCI excluding staged PCI. We also performed an analysis including only patients surviving at least 5 days. The median follow-up was 553 days. The primary end point occurred in 10.3% of patients in the staged complete revascularization group and in 16.3% of patients in the culprit lesion-only group (hazard ratio 0.61, 95% CI 0.38 to 0.95, p = 0.031). Although this difference was no longer significant when considering only the survivors at day 5, all-cause and cardiovascular mortalities were still reduced in the staged complete revascularization group. Complete revascularization was associated with a better outcome (hazard ratio 0.35, 95% CI 0.17 to 0.63, p = 0.005) if performed within 30 days of STEMI. In conclusion, compared with culprit lesion-only revascularization, in STEMI patients with MVD undergoing primary PCI, an approach of staged complete revascularization was associated with a better outcome.
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17
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Ahmad Y, Cook C, Shun-Shin M, Balu A, Keene D, Nijjer S, Petraco R, Baker CS, Malik IS, Bellamy MF, Sethi A, Mikhail GW, Al-Bustami M, Khan M, Kaprielian R, Foale RA, Mayet J, Davies JE, Francis DP, Sen S. Resolving the paradox of randomised controlled trials and observational studies comparing multi-vessel angioplasty and culprit only angioplasty at the time of STEMI. Int J Cardiol 2016; 222:1-8. [DOI: 10.1016/j.ijcard.2016.06.106] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 06/06/2016] [Accepted: 06/21/2016] [Indexed: 01/09/2023]
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18
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WITHDRAWN: Clinical outcomes of complete versus lesion only primary percutaneous coronary revascularization for multivessel disease and ST-segment elevation myocardial infarction. Indian Heart J 2016. [DOI: 10.1016/j.ihj.2016.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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19
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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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20
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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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21
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Chatterjee S, Yeh RW, Sardar P, Ul Hassan Virk H, Mukherjee D, Parikh SA, Kumbhani DJ, Kirtane A, Bashir R, Cohen H, Kolansky DM, Wilensky RL, Giri J. Is multivessel intervention in ST-elevation myocardial infarction associated with early harm? Insights from observational data. Catheter Cardiovasc Interv 2016; 88:697-707. [DOI: 10.1002/ccd.26643] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 06/05/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Saurav Chatterjee
- Division of Cardiology; St. Lukes-Roosevelt Hospitals of the Mount Sinai Health System; New York New York
| | - Robert W. Yeh
- Division of Cardiology; Massachusetts General Hospital; Boston Massachusetts
| | - Partha Sardar
- Division of Cardiology; University of Utah; Salt Lake City Utah
| | - Hafeez Ul Hassan Virk
- Division of Cardiology; St. Lukes-Roosevelt Hospitals of the Mount Sinai Health System; New York New York
| | | | - Sahil A. Parikh
- Cardiovascular Medicine Division; University Hospitals Case Medical Center, Harrington Heart and Vascular Institute and Case Western Reserve University School of Medicine; Cleveland Ohio
| | - Dharam J. Kumbhani
- Division of Cardiology; University of Texas Southwestern Medical School; Dallas Texas
| | - Ajay Kirtane
- Herbert and Sandi Feinberg Interventional Cardiology and Heart Valve Center at Columbia University Medical Center/New York-Presbyterian Hospital; New York New York
| | - Riyaz Bashir
- Division of Cardiology; Temple University School of Medicine; Philadelphia Pennsylvania
| | - Howard Cohen
- Division of Cardiology; Temple University School of Medicine; Philadelphia Pennsylvania
| | - Daniel M. Kolansky
- Cardiovascular Medicine Division; Perelman School of Medicine, University of Pennsylvania; Philadelphia Pennsylvania
| | - Robert L. Wilensky
- Cardiovascular Medicine Division; Perelman School of Medicine, University of Pennsylvania; Philadelphia Pennsylvania
| | - Jay Giri
- Cardiovascular Medicine Division; Perelman School of Medicine, University of Pennsylvania; Philadelphia Pennsylvania
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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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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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25
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Russo JJ, Wells GA, Chong AY, So DY, Glover CA, Froeschl MP, Hibbert B, Marquis JF, Dick A, Blondeau M, Bernick J, Labinaz M, Le May MR. 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). Am J Cardiol 2015; 116:1157-62. [PMID: 26282725 DOI: 10.1016/j.amjcard.2015.07.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 07/14/2015] [Accepted: 07/14/2015] [Indexed: 12/15/2022]
Abstract
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.
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26
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Ruggieri A, Piraino D, Dendramis G, Cortese B, Carella M, Buccheri D, Andolina G, Assennato P. STEMI patients and nonculprit lesions: To treat or not to treat? and when? A review of most recent literature. Catheter Cardiovasc Interv 2015; 87:1258-68. [DOI: 10.1002/ccd.26236] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 08/24/2015] [Indexed: 11/06/2022]
Affiliation(s)
- Aldo Ruggieri
- Section of Interventional Cardiology and Haemodynamics; A.O.U.P “Paolo Giaccone”; Palermo Italy
| | - Davide Piraino
- Section of Interventional Cardiology and Haemodynamics; A.O.U.P “Paolo Giaccone”; Palermo Italy
- Interventional Cardiology, A.O. Fatebenefratelli, Milan; Italy
| | - Gregory Dendramis
- Section of Interventional Cardiology and Haemodynamics; A.O.U.P “Paolo Giaccone”; Palermo Italy
- Section of Intensive Coronary Care Unit, A.O.U.P “Paolo Giaccone”; Palermo Italy
| | | | - Michele Carella
- Section of Interventional Cardiology and Haemodynamics; A.O.U.P “Paolo Giaccone”; Palermo Italy
| | - Dario Buccheri
- Section of Interventional Cardiology and Haemodynamics; A.O.U.P “Paolo Giaccone”; Palermo Italy
- Interventional Cardiology, A.O. Fatebenefratelli, Milan; Italy
| | - Giuseppe Andolina
- Section of Interventional Cardiology and Haemodynamics; A.O.U.P “Paolo Giaccone”; Palermo Italy
| | - Pasquale Assennato
- Section of Intensive Coronary Care Unit, A.O.U.P “Paolo Giaccone”; Palermo Italy
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27
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Engstrøm T, Kelbæk H, Helqvist S, Høfsten DE, Kløvgaard L, Holmvang L, Jørgensen E, Pedersen F, Saunamäki K, Clemmensen P, De Backer O, Ravkilde J, Tilsted HH, Villadsen AB, Aarøe J, Jensen SE, Raungaard B, Køber L. Complete revascularisation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multivessel disease (DANAMI-3—PRIMULTI): an open-label, randomised controlled trial. Lancet 2015; 386:665-71. [PMID: 26347918 DOI: 10.1016/s0140-6736(15)60648-1] [Citation(s) in RCA: 676] [Impact Index Per Article: 75.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with acute ST-segment elevation myocardial infarction (STEMI) and multivessel coronary disease have a worse prognosis compared with individuals with single-vessel disease. We aimed to study the clinical outcome of patients with STEMI treated with fractional flow reserve (FFR)-guided complete revascularisation versus treatment of the infarct-related artery only. METHODS We undertook an open-label, randomised controlled trial at two university hospitals in Denmark. Patients presenting with STEMI who had one or more clinically significant coronary stenosis in addition to the lesion in the infarct-related artery were included. After successful percutaneous coronary intervention (PCI) of the infarct-related artery, patients were randomly allocated (in a 1:1 ratio) either no further invasive treatment or complete FFR-guided revascularisation before discharge. Randomisation was done electronically via a web-based system in permuted blocks of varying size by the clinician who did the primary PCI. All patients received best medical treatment. The primary endpoint was a composite of all-cause mortality, non-fatal reinfarction, and ischaemia-driven revascularization of lesions in non-infarct-related arteries and was assessed when the last enrolled patient had been followed up for 1 year. Analysis was on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov, number NCT01960933. FINDINGS From March, 2011, to February, 2014, we enrolled 627 patients to the trial; 313 were allocated no further invasive treatment after primary PCI of the infarct-related artery only and 314 were assigned complete revascularization guided by FFR values. Median follow-up was 27 months (range 12–44 months). Events comprising the primary endpoint were recorded in 68 (22%) patients who had PCI of the infarct-related artery only and in 40 (13%) patients who had complete revascularisation (hazard ratio 0∙56, 95% CI 0∙38–0∙83; p=0∙004). INTERPRETATION In patients with STEMI and multivessel disease, complete revascularisation guided by FFR measurements significantly reduces the risk of future events compared with no further invasive intervention after primary PCI. This effect is driven by significantly fewer repeat revascularisations, because all-cause mortality and non-fatal reinfarction did not differ between groups. Thus, to avoid repeat revascularisation, patients can safely have all their lesions treated during the index admission. Future studies should clarify whether complete revascularization should be done acutely during the index procedure or at later time and whether it has an effect on hard endpoints. FUNDING Danish Agency for Science, Technology and Innovation and Danish Council for Strategic Research.
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Influence of multivessel disease with or without additional revascularization on mortality in patients with ST-segment elevation myocardial infarction. Am Heart J 2015; 170:70-8. [PMID: 26093866 DOI: 10.1016/j.ahj.2015.03.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 03/18/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND In patients with ST-segment elevation myocardial infarction (STEMI), timely reperfusion with primary percutaneous coronary intervention (PCI) is the preferred treatment. In primary PCI patients with multivessel disease, it is unclear whether culprit vessel PCI only is the preferred treatment. We compared mortality among (1) STEMI patients with single-vessel disease and those with multivessel disease and (2) multivessel disease patients with and without additional revascularization of nonculprit lesions within 2 months after the index PCI. METHODS From January 2002 to June 2009, all patients presenting with STEMI and treated with primary PCI were identified from the Western Denmark Heart Registry, which covers a population of 3.0 million. The hazard ratio (HR) for death was estimated using a Cox regression model, controlling for potential confounding. RESULTS The study cohort consisted of 8,822 patients: 4,770 (54.1%) had single-vessel disease and 4,052 (45.9%) had multivessel disease. Overall, 1-year cumulative mortality was 7.6%, and 7-year cumulative mortality was 24.0%. Multivessel disease was associated with higher 7-year mortality (adjusted HR 1.45 [95% CI 1.30-1.62], P < .001). Among patients with multivessel disease, lack of additional revascularization beyond the culprit lesion was associated with higher 7-year mortality (adjusted HR 1.50 [95% CI 1.25-1.80], P < .001). In patients with multivessel disease who underwent additional revascularization, 7-year mortality (adjusted HR 1.01 [95% CI 0.84-1.22], P = .89) was similar compared to patients with single-vessel disease. CONCLUSION In STEMI patients, multivessel disease was associated with a higher mortality compared to single-vessel disease. In multivessel disease patients, additional revascularization was associated with a higher survival compared with culprit vessel PCI only.
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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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El-Hayek GE, Gershlick AH, Hong MK, Casso Dominguez A, Banning A, Afshar AE, Herzog E, Tamis-Holland JE. Meta-Analysis of Randomized Controlled Trials Comparing Multivessel Versus Culprit-Only Revascularization for Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Disease Undergoing Primary Percutaneous Coronary Intervention. Am J Cardiol 2015; 115:1481-6. [PMID: 25840579 DOI: 10.1016/j.amjcard.2015.02.046] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Revised: 02/26/2015] [Accepted: 02/26/2015] [Indexed: 10/23/2022]
Abstract
Current guidelines recommend against revascularization of the noninfarct artery during the index percutaneous coronary intervention (PCI) in hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI). This was based largely on observational studies with few data coming from randomized controlled trials (RCTs). Recently, several small-to-moderate sized RCTs have provided data, suggesting that a multivessel revascularization approach may be appropriate. We performed a meta-analysis of RCTs comparing multivessel percutaneous coronary intervention (MV PCI) versus culprit vessel-only revascularization (COR) during primary PCI in patients with STEMI and multivessel coronary disease (MVCD). We searched Medline, PubMed, and Scopus databases for RCTs comparing MV PCI versus COR in patients with STEMI and MVCD. The incidence of all-cause death, cardiac death, recurrent myocardial infarction, and revascularization during follow-up were extracted. Four RCTs fit our primary selection criteria. Among these, 566 patients underwent MV PCI (either at the time of the primary PCI or as a staged procedure) and 478 patients underwent COR. During long-term follow-up (range 1 to 2.5 years), combined data indicated a significant reduction in all-cause mortality (relative risk [RR] 0.57, 95% confidence interval [CI] 0.36 to 0.92, p = 0.02) and in cardiac death (RR 0.38, 95% CI 0.20 to 0.73, p = 0.004) with MV PCI. In addition, there was a significantly lower risk of recurrent myocardial infarction (RR 0.41, 95% CI 0.23 to 0.75; p = 0.004) and future revascularization (RR 0.37, 95% CI 0.27 to 0.52; p <0.00001). In conclusion, from the RCT data, MV PCI appears to improve outcomes in patients with STEMI and MVCD.
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Bittl JA, Tamis-Holland JE, Lang CD, He Y. Outcomes after multivessel or culprit-Vessel intervention for ST-elevation myocardial infarction in patients with multivessel coronary disease: A Bayesian cross-design meta-analysis. Catheter Cardiovasc Interv 2015; 86 Suppl 1:S15-22. [DOI: 10.1002/ccd.26025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 04/06/2015] [Accepted: 04/18/2015] [Indexed: 11/06/2022]
Affiliation(s)
| | | | | | - Yulei He
- Office of Research and Methodology; National Center for Health Statistics, Centers for Disease Control and Prevention; Hyattsville Maryland
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Rasoul S, van Ommen V, Vainer J, Ilhan M, Veenstra L, Erdem R, Ruiters LAW, Theunissen R, Hoorntje JCA. Multivessel revascularisation versus infarct-related artery only revascularisation during the index primary PCI in STEMI patients with multivessel disease: a meta-analysis. Neth Heart J 2015; 23:224-31. [PMID: 25884095 PMCID: PMC4368524 DOI: 10.1007/s12471-015-0674-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background There are controversial data regarding infarct-related artery only (IRA-PCI) revascularisation versus multivessel revascularisation (MV-PCI) in ST-elevation myocardial infarction (STEMI) patients with multivessel disease undergoing primary percutaneous coronary intervention (PCI). We performed a meta-analysis comparing outcome in same stage MV-PCI versus IRA-PCI in STEMI patients with multivessel disease. Methods Systematic searches of studies comparing MV-PCI with IRA-PCI in the MEDLINE and the Cochrane Database of systematic reviews were conducted. A meta-analysis was performed of all available studies. Primary outcome was all-cause mortality. Secondary endpoints were re-infarction, revascularisation, bleeding and major adverse cardiac events (MACE). Results A total of 15 studies were identified with a total number of 35,975 patients. Mortality rate was significantly higher in the MV-PCI group compared with the IRA-PCI group, odds ratio (OR): 1.64 (1.46–1.85). Both the incidence of re-infarction and re-PCI were significantly lower in the MV-PCI group compared with the IRA-PCI group: OR 0.54 (0.34–0.88) and OR 0.67 (0.48–0.93), respectively. Bleeding complications occurred more often in the MV-PCI group as compared with the IRA-PCI group: OR 1.24 (1.08–1.42). Rates of MACE were comparable between the two groups. Conclusions MV-PCI during the index of primary PCI in STEMI patients is associated with a higher mortality rate, a higher risk of bleeding complications, but lower risk of re-intervention and re-infarction and comparable rates of MACE.
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Affiliation(s)
- S Rasoul
- Department of Cardiology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands,
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Bangalore S, Toklu B, Wetterslev J. Complete Versus Culprit-Only Revascularization for ST-Segment–Elevation Myocardial Infarction and Multivessel Disease. Circ Cardiovasc Interv 2015; 8:CIRCINTERVENTIONS.114.002142. [DOI: 10.1161/circinterventions.114.002142] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The 2013 American College of Cardiology Foundation/American Heart Association guidelines for patients with ST-segment–elevation myocardial infarction gives a class III indication for nonculprit artery percutaneous coronary intervention at the time of primary percutaneous coronary intervention, driven by data from observational studies. However, more recent trials suggest otherwise.
Methods and Results—
We conducted PUBMED, EMBASE, and CENTRAL searches for randomized trials comparing complete versus culprit-only revascularization in patients with ST-segment–elevation myocardial infarction. Efficacy outcomes were major adverse cardiovascular events, as well as death, cardiovascular death, myocardial infarction, and repeat revascularization. Safety outcomes were contrast-induced nephropathy, contrast volume used, and procedure time. Five trials with 1165 patients fulfilled the inclusion criteria. Complete revascularization (68% during index percutaneous coronary intervention) was associated with significant reduction in major adverse cardiovascular events (rate ratio =0.48; 95% confidence interval =0.37–0.61), death (rate ratio =0.60; 95% confidence interval =0.38–0.97), cardiovascular death (rate ratio =0.38, 95% confidence interval =0.20–0.73), and repeat revascularization (rate ratio =0.42; 95% confidence interval =0.31–0.57) when compared with culprit-only revascularization. However, trial sequential analyses (similar to interim analysis of a randomized trial) powered for a 25% relative reduction showed firm evidence (cumulative z-curve crossed the monitoring boundary) only for major adverse cardiovascular events driven by a decrease in repeat revascularization with no firm evidence for reduction in death and myocardial infarction. Moreover, there was a significant increase in contrast volume use (mean difference 85.12 [70.41–83.00] ml) and procedure time (mean difference 16.42 [13.22–19.63] mins) with complete revascularization without increase in contrast-induced nephropathy.
Conclusions—
In patients with ST-segment–elevation myocardial infarction, immediate or staged complete revascularization results in significant reduction in major adverse cardiovascular events driven largely by reduction in repeat revascularization with no firm evidence for the reduction in death or myocardial infarction when compared with culprit-only revascularization.
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Affiliation(s)
- Sripal Bangalore
- From the Division of Cardiology, New York University School of Medicine, New York, NY (S.B., B.T.); and Division of Cardiology, The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (J.W.)
| | - Bora Toklu
- From the Division of Cardiology, New York University School of Medicine, New York, NY (S.B., B.T.); and Division of Cardiology, The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (J.W.)
| | - Jørn Wetterslev
- From the Division of Cardiology, New York University School of Medicine, New York, NY (S.B., B.T.); and Division of Cardiology, The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (J.W.)
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SONG YEOJEONG, SHIN HOCHEOL, YANG JOOII, LEE HOYOUNG, JIN HANYOUNG, SEO JEONGSOOK, YANG TAEHYUN, KIM DAEKYEONG, KIM DONGSOO, JANG JAESIK. Preventive versus Culprit-Only Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction Patients with Multivessel Disease: A Meta-Analysis. J Interv Cardiol 2015; 28:1-13. [DOI: 10.1111/joic.12167] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- YEO-JEONG SONG
- Department of Cardiology; Inje University Busan Paik Hospital; Busan Korea
| | - HO-CHEOL SHIN
- Department of Cardiology; Inje University Busan Paik Hospital; Busan Korea
| | - JOO-II YANG
- Department of Cardiology; Inje University Busan Paik Hospital; Busan Korea
| | - HO-YOUNG LEE
- Department of Cardiology; Inje University Busan Paik Hospital; Busan Korea
| | - HAN-YOUNG JIN
- Department of Cardiology; Inje University Busan Paik Hospital; Busan Korea
| | - JEONG-SOOK SEO
- Department of Cardiology; Inje University Busan Paik Hospital; Busan Korea
| | - TAE-HYUN YANG
- Department of Cardiology; Inje University Busan Paik Hospital; Busan Korea
| | - DAE-KYEONG KIM
- Department of Cardiology; Inje University Busan Paik Hospital; Busan Korea
| | - DONG-SOO KIM
- Department of Cardiology; Inje University Busan Paik Hospital; Busan Korea
| | - JAE-SIK JANG
- Department of Cardiology; Inje University Busan Paik Hospital; Busan Korea
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Sarathy K, Nagaraja V, Kapur A, Szirt R, Raval J, Eslick GD, Burgess D, Denniss AR. Target-vessel versus multivessel revascularisation in ST-elevation myocardial infarction: a meta-analysis of randomised trials. Heart Lung Circ 2014; 24:327-34. [PMID: 25547531 DOI: 10.1016/j.hlc.2014.10.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Revised: 09/10/2014] [Accepted: 10/15/2014] [Indexed: 02/06/2023]
Abstract
INTRODUCTION In acute ST-segment elevation myocardial infarction (STEMI), coronary reperfusion with percutaneous coronary intervention (PCI) to treat the culprit lesion responsible for infarction improves clinical outcomes in nearly all patients. The concurrent treatment of non-infarct vessels with significant stenoses during initial angiography remains an area of controversy. METHODS A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane Library, Google Scholar, Science Direct, and Web of Science. Original data were abstracted from each study and used to calculate a pooled odds ratio (OR) and 95% confidence interval (95% CI). RESULTS Only four randomised trials comprising 775 patients met full criteria for analysis. The incidence of non-fatal MI (3.25% vs 8.51%, OR: 0.376, 95% CI: 0.192-0.763), refractory angina (4.01% vs 9.57%, OR: 0.400, 95% CI: 0.241-0.741) and repeat revascularisation (10.52% vs 24.20%, OR: 0.336, 95% CI: 0.202-0.661) was lower in the multivessel revascularisation cohort. Death from cardiac causes or refractory angina or non-fatal MI (11.78% vs 28.86%, OR: 0.336, 95% CI: 0.223-0.505) and death from cardiac causes or non-fatal MI (5.26% vs 12.76%, OR: 0.420, 95% CI: 0.245-0.722) were significantly lower in the multivessel revascularisation cohort. The Median Contrast Volume and Procedure Length were similar in both cohorts. CONCLUSIONS In patients with acute STEMI who undergo primary PCI, a strategy of treatment of significant non-infarct stenosis (preventive PCI) in addition to the culprit lesion responsible for infarction may result in improved cardiovascular outcomes and reduced overall mortality; however there is insufficient data to fully validate this from currently published literature.
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Affiliation(s)
- Kiran Sarathy
- Prince of Wales Hospital, University of New South Wales, Sydney
| | - Vinayak Nagaraja
- Prince of Wales Hospital, University of New South Wales, Sydney; The Whiteley-Martin Research Centre, University of Sydney, Nepean Hospital, Sydney
| | - Amit Kapur
- Prince of Wales Hospital, University of New South Wales, Sydney
| | - Richard Szirt
- Prince of Wales Hospital, University of New South Wales, Sydney
| | - Jwalant Raval
- Department of Cardiology, Blacktown Hospital, Sydney.
| | - Guy D Eslick
- The Whiteley-Martin Research Centre, University of Sydney, Nepean Hospital, Sydney
| | - David Burgess
- Department of Cardiology, Blacktown Hospital, Sydney
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Bailey SR. Revascularization for ST segment elevation MI: advances in treatment of multivessel disease in STEMI. Catheter Cardiovasc Interv 2014; 84:857-8. [PMID: 25352188 DOI: 10.1002/ccd.25703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Steven R Bailey
- University of Texas Health Science Center San Antonio, Texas
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Pollack A, Mohanty BD, Handa R, Looser PM, Fuster V, King SB, Sharma SK. Preventive stenting in acute myocardial infarction. JACC Cardiovasc Interv 2014; 8:131-138. [PMID: 25616917 DOI: 10.1016/j.jcin.2014.09.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 09/08/2014] [Accepted: 09/30/2014] [Indexed: 11/25/2022]
Abstract
Current practice guidelines advocate culprit vessel intervention alone in patients with ST-segment elevation myocardial infarction (STEMI) found to have multivessel coronary disease during primary percutaneous coronary intervention (PCI). The debate on the timing of noninfarct artery intervention has recently been reinvigorated by the PRAMI (Preventive Angioplasty in Acute Myocardial Infarction) trial, in which patients undergoing preventive PCI of significant nonculprit lesions at the time primary PCI for STEMI had reduced rates of cardiac death, nonfatal myocardial infarction, and refractory angina. Given that previous literature has cautioned against multivessel PCI during STEMI, this raises the question of whether technical and pharmacological advances in PCI may have opened the door to safely revisit this issue with additional clinical rigor. The impact of STEMI pathophysiology on nonculprit vessel plaque, how treatment of nonculprit lesions alters the natural history of coronary disease after STEMI, and whether this results in a clinical benefit remain unclear, and much of the existing data are retrospective. Additionally, the PRAMI trial did not include a staged PCI, leaving questions as to how this approach might fare compared with simultaneous preventive PCI. In this review, we discuss the pathophysiology of nonculprit vessel plaque in STEMI, provide a summary of the existing literature on the topic, and discuss the PRAMI trial in the face of previous data and possible future directions for further study.
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Affiliation(s)
- Ari Pollack
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Heart, New York, New York
| | - Bibhu D Mohanty
- Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rishi Handa
- Department of Medicine, Morristown Medical Center, Morristown, New Jersey.
| | - Patrick M Looser
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Valentin Fuster
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Heart, New York, New York
| | | | - Samin K Sharma
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Heart, New York, New York
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Dahal K, Rijal J, Panta R, Lee J, Azrin M, Lootens R. Multi-vessel versus culprit-vessel and staged percutaneous coronary intervention in STEMI patients with multivessel disease: a meta-analysis of randomized controlled trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2014; 15:408-13. [PMID: 25454258 DOI: 10.1016/j.carrev.2014.10.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Revised: 10/06/2014] [Accepted: 10/10/2014] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Percutaneous coronary intervention (PCI) is preferred in patients with acute ST-elevation myocardial infarction (STEMI). In patients with acute STEMI with multivessel disease (MVD), the guidelines recommend culprit vessel PCI (CV-PCI) in the absence of hemodynamic instability. We performed a meta-analysis of all randomized controlled trials (RCTs) comparing multi-vessel PCI (MV-PCI) with CV-PCI or staged PCI (S-PCI) in patients with acute STEMI and MVD. METHODS PubMed, EMBASE and CENTRAL were searched for publications since inception to December 2013. Random effects model was used to compute summary effects. RESULTS Four RCTs (840 patients) were identified. MV-PCI compared to CV-PCI significantly reduced the risks of major adverse cardiac events (MACE)-a composite of MI, revascularization and all-cause mortality (RR: 0.46, 95% CI: 0.35-0.60, P<0.00001) by reducing the risks of MI (0.35, 0.17-0.71, P=0.004) and revascularization (0.35, 0.24-0.52, P<0.00001). The risk of all-cause mortality was not different (0.69, 0.39-1.21, P=0.19). S-PCI and MV-PCI had similar risks of MACE (0.96, 0.59-1.57, P=0.87), MI (0.60, 0.20-1.78, P=0.36), revascularization (0.86, 0.47-1.54, P=0.60) and all-cause mortality (1.50, 0.44-5.07, P=0.57). CONCLUSIONS MV-PCI compared to CV-PCI resulted in lower risks of MACE driven by lower MI and revascularization in patients with STEMI and multi-vessel disease.
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Affiliation(s)
| | - Jharendra Rijal
- Department of Medicine, Miriam Hospital, Brown University, Providence, RI
| | - Raju Panta
- Department of Medicine, LRGHealthcare, Laconia, NH
| | - Juyong Lee
- Calhoun Cardiology Center, University of Connecticut Health Center, Farmington, CT
| | - Michael Azrin
- Calhoun Cardiology Center, University of Connecticut Health Center, Farmington, CT
| | - Robert Lootens
- Department of Medicine, LRGHealthcare, Laconia, NH; Concord Cardiac Associates, Dartmouth Hitchcock Medical Center, Concord, NH
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Harries I, Ramcharitar S. Total revascularization of coronary disease at the time of primary percutaneous coronary intervention. Future Cardiol 2014; 10:451-5. [DOI: 10.2217/fca.14.30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Iwan Harries
- Wiltshire Cardiac Centre, Department of Interventional Cardiology, Marlborough Road, Swindon, SN3 6BB, UK
| | - Steve Ramcharitar
- Wiltshire Cardiac Centre, Department of Interventional Cardiology, Marlborough Road, Swindon, SN3 6BB, UK
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Kim MC, Jeong MH, Kim SH, Hong YJ, Kim JH, Ahn Y. Current Status of Coronary Intervention in Patients with ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Artery Disease. Korean Circ J 2014; 44:131-8. [PMID: 24876852 PMCID: PMC4037633 DOI: 10.4070/kcj.2014.44.3.131] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Primary percutaneous coronary intervention (PCI) is a standard interventional treatment modality for ST-segment elevation myocardial infarction (STEMI). Diagnostic coronary angiogram during PCI reveals multivessel coronary artery disease in about half of patients with STEMI, and it is difficult to make decision on the extent of intervention in these patients. Although revascularization for the infarct-related artery only is still effective for STEMI patients, several studies have reported the efficacy of multivessel revascularization during primary PCI, as well as in a staged PCI procedure. Clinicians should consider clinical aspects such as initial cardiogenic shock and myocardial viability when performing primary multivessel intervention, including the risks and benefits of multivessel revascularization in patients undergoing primary PCI. This review describes the current status of performing multivessel PCI in patients with STEMI and proposes an optimal revascularization strategy based on the previous literature.
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Affiliation(s)
- Min Chul Kim
- Department of Cardiovascular Medicine, Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Myung Ho Jeong
- Department of Cardiovascular Medicine, Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Sang Hyung Kim
- Department of Cardiovascular Medicine, Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Young Joon Hong
- Department of Cardiovascular Medicine, Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Ju Han Kim
- Department of Cardiovascular Medicine, Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Youngkeun Ahn
- Department of Cardiovascular Medicine, Heart Center, Chonnam National University Hospital, Gwangju, Korea
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Jeger R, Jaguszewski M, Nallamothu BN, Lüscher TF, Urban P, Pedrazzini GB, Erne P, Radovanovic D. Acute multivessel revascularization improves 1-year outcome in ST-elevation myocardial infarction. Int J Cardiol 2014; 172:76-81. [DOI: 10.1016/j.ijcard.2013.12.083] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 11/26/2013] [Accepted: 12/20/2013] [Indexed: 10/25/2022]
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Percutaneous coronary intervention for nonculprit vessels in cardiogenic shock complicating ST-segment elevation acute myocardial infarction. Crit Care Med 2014; 42:17-25. [PMID: 24105454 DOI: 10.1097/ccm.0b013e3182a2701d] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES We investigated the clinical impact of multivessel percutaneous coronary intervention in ST-segment elevation myocardial infarction complicated by cardiogenic shock with multivessel disease. DESIGN A prospective, multicenter, observational study. SETTING Cardiac ICU of a university hospital. PATIENTS Between November 2005 and September 2010, 338 patients were selected. Inclusion criteria were as follows: 1) ST-segment elevation myocardial infarction with cardiogenic shock and 2) multivessel disease with successful primary percutaneous coronary intervention for the infarct-related artery. Patients were divided into multivessel percutaneous coronary intervention and culprit-only percutaneous coronary intervention. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Primary outcome was all-cause mortality. Median follow-up duration was 224 days (interquartile range, 46-383 d). Multivessel percutaneous coronary intervention was performed during the primary percutaneous coronary intervention in 60 patients (17.8%). In-hospital mortality was similar in both groups (multivessel percutaneous coronary intervention vs culprit-only percutaneous coronary intervention, 31.7% vs 24.5%; p = 0.247). All-cause mortality during follow-up was not significantly different between the two groups after adjusting for patient, angiographic, and procedural characteristics as well as propensity scores for receiving multivessel percutaneous coronary intervention (35.0% vs 30.6%; adjusted hazard ratio, 1.06; 95% CI, 0.61-1.86; p = 0.831). There were no significant differences between the groups in rates of major adverse cardiac events (41.7% vs 37.1%; adjusted hazard ratio, 1.03; 95% CI, 0.62-1.71; p = 0.908) and any revascularization (6.7% vs 4.7%; adjusted hazard ratio, 1.88; 95% CI, 0.51-6.89; p = 0.344). CONCLUSIONS Multivessel percutaneous coronary intervention could not reduce the prevalence of mortality in patients with cardiogenic shock complicating ST-segment elevation myocardial infarction and multivessel disease during primary percutaneous coronary intervention.
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Pandit A, Aryal MR, Aryal Pandit A, Hakim FA, Giri S, Mainali NR, Sharma P, Lee HR, Fortuin FD, Mookadam F. Preventive PCI versus culprit lesion stenting during primary PCI in acute STEMI: a systematic review and meta-analysis. Open Heart 2014; 1:e000012. [PMID: 25332779 PMCID: PMC4189298 DOI: 10.1136/openhrt-2013-000012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 01/22/2014] [Accepted: 01/25/2014] [Indexed: 11/09/2022] Open
Abstract
Aim The benefit of preventive percutaneous coronary intervention (PCI) in ST elevation myocardial infarction (STEMI) has been shown in randomised trials. However, all the randomised trials are underpowered to detect benefit in cardiac death. We aim to systematically review evidence on the cardiac mortality benefit of preventive PCI in patients presenting with acute STEMI in randomised patient populations. Methods PubMed, Scopus, Cochrane and clinicaltrials.gov databases were searched for studies published until 30 September 2013. The studies were limited to randomised clinical trials. Independent observers abstracted the data on outcomes, characteristics and qualities of studies included. Fixed effect model was employed for meta-analysis. Heterogeneity of studies included was analysed using I2 statistics. Results In three randomised clinical trials published, involving 748 patients with acute STEMI and multivessel disease, 416 patients were randomised to preventive PCI and 332 to culprit-only PCI. Patients undergoing preventive PCI had significant lower risk of cardiovascular deaths (pooled OR 0.39, 95% CI 0.18 to 0.83, p=0.01, I2=0%), repeat revascularisation (pooled OR 0.28, 95% CI 0.18 to 0.44, p=0.00001, I2=0%) and non-fatal myocardial infarction (pooled OR 0.38, 95% CI 0.20 to 0.75, p=0.005, I2=0%) compared with culprit-only revascularisation. Conclusions In patients presenting with acute STEMI and significant multivessel coronary artery disease, based on our data, preventive PCI is associated with lower risk of cardiovascular mortality compared with primary PCI of only the culprit artery. This finding needs to be confirmed in larger adequately powered randomised clinical trials.
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Affiliation(s)
- Anil Pandit
- Division of Cardiovascular Diseases , Mayo Clinic , Scottsdale, Arizona , USA
| | - Madan Raj Aryal
- Department of Internal Medicine , Reading Hospital , West Reading, Pennsylvania , USA
| | | | - Fayaz Ahmad Hakim
- Division of Cardiovascular Diseases , Mayo Clinic , Scottsdale, Arizona , USA
| | - Smith Giri
- Department of Internal Medicine , University of Tennessee , Memphis, Tennessee , USA
| | - Naba Raj Mainali
- Department of Internal Medicine , Reading Hospital , West Reading, Pennsylvania , USA
| | - Prashant Sharma
- Department of Internal Medicine , Mayo Clinic , Rochester, Minnesota , USA
| | - Howard R Lee
- Division of Cardiovascular Diseases , Mayo Clinic , Scottsdale, Arizona , USA
| | - F David Fortuin
- Division of Cardiovascular Diseases , Mayo Clinic , Scottsdale, Arizona , USA
| | - Farouk Mookadam
- Division of Cardiovascular Diseases , Mayo Clinic , Scottsdale, Arizona , USA
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Manari A, Varani E, Guastaroba P, Menozzi M, Valgimigli M, Menozzi A, Magnavacchi P, Franco N, Marzocchi A, Casella G. Long-term outcome in patients with ST segment elevation myocardial infarction and multivessel disease treated with culprit-only, immediate, or staged multivessel percutaneous revascularization strategies: Insights from the REAL registry. Catheter Cardiovasc Interv 2014; 84:912-22. [DOI: 10.1002/ccd.25374] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 12/02/2013] [Accepted: 12/21/2013] [Indexed: 12/11/2022]
Affiliation(s)
- Antonio Manari
- Interventional Cardiology Unit; Azienda Ospedaliera S. Maria Nuova - IRCCS Reggio Emilia Italy
| | - Elisabetta Varani
- Division of Cardiology and Interventional Center; Ospedale S. Maria delle Croci Ravenna Italy
| | - Paolo Guastaroba
- Regional Health Care Agency; Regione Emilia-Romagna Bologna Italy
| | - Mila Menozzi
- Interventional Cardiology Unit; Azienda Ospedaliera S. Maria Nuova - IRCCS Reggio Emilia Italy
| | - Marco Valgimigli
- Cardiovascular Institute; Azienda Ospedaliero-Universitaria S. Anna Ferrara Italy
| | - Alberto Menozzi
- Division of Cardiology and Cardiac Catheterization Laboratory; Azienda Ospedaliero-Universitaria; Parma Italy
| | - Paolo Magnavacchi
- Division of Cardiology and Cardiac Catheterization Laboratory; Nuovo Ospedale Civile S. Agostino-Estense; Modena Italy
| | - Nicoletta Franco
- Division of Cardiology and Cardiac Catheterization Laboratory; Ospedale Infermi; Rimini Italy
| | - Antonio Marzocchi
- Institute of Cardiology, Azienda Ospedaliero-Universitaria Policlinico S. Orsola-Malpighi; Bologna Italy
| | - Gianni Casella
- Division of Cardiology and Cardiac Catheterization Laboratory; Ospedale Maggiore; Bologna Italy
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Multivessel approach in ST‐elevation myocardial infarction: Impact on in‐hospital morbidity and mortality. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.repce.2013.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Santos AR, Cordeiro Piçarra B, Celeiro M, Bento Â, Aguiar J. Abordagem multivaso no enfarte agudo do miocárdio com elevação do segmento ST: impacto na morbilidade e mortalidade intra‐hospitalares. Rev Port Cardiol 2014; 33:67-73. [DOI: 10.1016/j.repc.2013.07.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2012] [Revised: 07/22/2013] [Accepted: 07/22/2013] [Indexed: 11/30/2022] Open
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Bainey KR, Mehta SR, Lai T, Welsh RC. Complete vs culprit-only revascularization for patients with multivessel disease undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: a systematic review and meta-analysis. Am Heart J 2014; 167:1-14.e2. [PMID: 24332136 DOI: 10.1016/j.ahj.2013.09.018] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 09/30/2013] [Indexed: 12/28/2022]
Abstract
BACKGROUND Patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease who undergo primary percutaneous coronary intervention (PCI) are most commonly treated with PCI to the culprit lesion only. Whether a strategy of complete revascularization in these patients is superior is unknown. We performed a meta-analysis comparing the benefits and risks of routine culprit-only PCI vs multivessel PCI in STEMI. METHODS MEDLINE, EMBASE, ISI Web of Science, and The Cochrane Register of Controlled Trials were searched from 1996 to January 2011. Relevant conference abstracts were searched from January 2002 to January 2011. Studies included STEMI with multivessel disease receiving primary PCI. The primary end point was long-term mortality. Data were combined using a fixed-effects model. RESULTS Of 507 citations, 26 studies (3 randomized, 23 nonrandomized; 46,324 patients, 7886 multivessel PCI and 38,438 culprit-only PCI) were included. There was no significant difference in hospital mortality with multivessel PCI vs culprit-only PCI (odds ratio [OR] 1.11, 95% CI 0.98-1.25, P = .10 [randomized OR 0.24, 95% CI 0.06-0.91, P = .04; nonrandomized OR 1.12, 95% CI 1.00-1.27, P = .06]). However, if multivessel PCI during index catheterization was performed, hospital mortality was increased (OR 1.35, 95% CI 1.19-1.54, P < .001). When multivessel PCI was performed as a staged procedure, hospital mortality was lower (OR 0.35, 95% CI 0.21-0.59; P < .001; P interaction < .001). Reduced long-term mortality (OR 0.74, 95% CI 0.65-0.85, P < .001[randomized OR 0.61, 95% CI 0.28-1.33, P = .22; nonrandomized OR 0.75, 95% CI 0.65-0.86, P < .001]) and repeat PCI (OR 0.65; 95% 0.46-0.90, P = .01[randomized OR 0.31, 95% CI 0.17-0.57, P < .001; nonrandomized OR 0.88, 95% CI 0.59-1.31, P = .54]) were observed with multivessel PCI. CONCLUSION Overall, staged multivessel PCI improved short- and long-term survival and reduced repeat PCI. Still, large randomized trials are required to confirm the benefits of staged multivessel PCI in STEMI.
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Zimmermann S, Rohde D, Marwan M, Ludwig J, Achenbach S. Complete recovery after out-of-hospital cardiac arrest with prolonged (59 min) mechanical cardiopulmonary resuscitation, mild therapeutic hypothermia and complex percutaneous coronary intervention for ST-elevation myocardial infarction. Heart Lung 2014; 43:62-5. [DOI: 10.1016/j.hrtlng.2013.10.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 10/14/2013] [Accepted: 10/17/2013] [Indexed: 11/29/2022]
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Jaguszewski M, Radovanovic D, Nallamothu BK, Lüscher TF, Urban P, Eberli FR, Bertel O, Pedrazzini GB, Windecker S, Jeger R, Erne P. Multivessel versus culprit vessel percutaneous coronary intervention in ST-elevation myocardial infarction: is more worse? EUROINTERVENTION 2013; 9:909-915. [DOI: 10.4244/eijv9i8a153] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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The great taboo of non-infarct-related artery revascularization during primary percutaneous coronary intervention. Am Heart J 2013; 166:611-3. [PMID: 24093838 DOI: 10.1016/j.ahj.2013.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 06/29/2013] [Indexed: 11/20/2022]
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