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Durmaz E, Ikitimur B, Arapi B, Tel Ustunisik C, Soysal AU, İncesu G, Gulfidan A, Yalman H, Cidem S, Tokdil H, Raimoglu U, Raimoglou D, Akman Z, Atici A, Karadag B. The impact of ticagrelor therapy on CABG-related bleeding in patients with STEMI managed with pPCI and following on-pump CABG. Heart Vessels 2024:10.1007/s00380-024-02434-1. [PMID: 39030310 DOI: 10.1007/s00380-024-02434-1] [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] [Received: 12/03/2023] [Accepted: 06/24/2024] [Indexed: 07/21/2024]
Abstract
Patients on double antiplatelet treatment who need early in-hospital coronary artery bypass grafting (CABG) are at high risk of major bleeding. In this study, we aimed to investigate the impact of ticagrelor preloading on CABG related bleeding in patients with ST-segment elevation myocardial infarction (STEMI) initially managed with primary percutaneous coronary intervention (pPCI). Patients with the diagnosis of STEMI who were managed with pPCI and underwent subsequent early (4-7 days following pPCI) or delayed (> 7 days following pPCI) on-pump CABG surgery were included. All study patients were preloaded with ticagrelor 180 mg prior to pPCI procedure. Patients' demographics, clinical variables, and short-term cardiovascular outcomes were recorded. This is a retrospective study which included 98 patients. Fifty-four (54%) patients underwent early and 44 (45%) patients underwent delayed CABG surgery. CABG-related bleeding occurred in 22 (22.4%) patients. There was no significant difference with respect to total ticagrelor dose and timing of the surgery between patients with or without CABG-related bleeding (p: 0.165 and p: 0.142). Multivariate analyses demonstrated that only preoperative hemoglobin level < 10.9 and use of mechanical cardiac support devices were independent predictors of CABG-related bleeding [OR: 3719, p: 0.009 and OR: 11,698, p: 0.004, respectively].There were three deaths within the 30 days of surgery, all occurring in patients with CABG-related bleeding. However, CABG-related bleeding was not associated with long-term cardiovascular events during the follow-up. Our results indicated that discontinuation of ticagrelor therapy 3 days prior to surgery is sufficient to avoid CABG-related bleeding. Moreover, early CABG following STEMI does not increase the risk of long-term cardiovascular events.
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Affiliation(s)
- Eser Durmaz
- Department of Cardiology, Cerrahpasa School of Medicine, Cerrahpasa/Fatih, Istanbul University-Cerrahpasa, Kocamustafapasa Street, 34098, Istanbul, Turkey.
| | - Baris Ikitimur
- Department of Cardiology, Cerrahpasa School of Medicine, Cerrahpasa/Fatih, Istanbul University-Cerrahpasa, Kocamustafapasa Street, 34098, Istanbul, Turkey
| | - Berk Arapi
- Department of Cardiovascular Surgery, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Cigdem Tel Ustunisik
- Department of Cardiology, Istanbul Medeniyet University, Goztepe Research and Training Hospital, Istanbul, Turkey
| | - Ali Ugur Soysal
- Department of Cardiology, Cerrahpasa School of Medicine, Cerrahpasa/Fatih, Istanbul University-Cerrahpasa, Kocamustafapasa Street, 34098, Istanbul, Turkey
| | - Gunduz İncesu
- Department of Cardiology, Cerrahpasa School of Medicine, Cerrahpasa/Fatih, Istanbul University-Cerrahpasa, Kocamustafapasa Street, 34098, Istanbul, Turkey
| | - Aslı Gulfidan
- Department of Cardiology, Cerrahpasa School of Medicine, Cerrahpasa/Fatih, Istanbul University-Cerrahpasa, Kocamustafapasa Street, 34098, Istanbul, Turkey
| | - Hakan Yalman
- Department of Cardiology, Cerrahpasa School of Medicine, Cerrahpasa/Fatih, Istanbul University-Cerrahpasa, Kocamustafapasa Street, 34098, Istanbul, Turkey
| | - Savas Cidem
- Department of Cardiovascular Surgery, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Hasan Tokdil
- Department of Cardiology, Cerrahpasa School of Medicine, Cerrahpasa/Fatih, Istanbul University-Cerrahpasa, Kocamustafapasa Street, 34098, Istanbul, Turkey
| | - Utku Raimoglu
- Department of Cardiology, Cerrahpasa School of Medicine, Cerrahpasa/Fatih, Istanbul University-Cerrahpasa, Kocamustafapasa Street, 34098, Istanbul, Turkey
| | - Damla Raimoglou
- Department of Cardiology, Cerrahpasa School of Medicine, Cerrahpasa/Fatih, Istanbul University-Cerrahpasa, Kocamustafapasa Street, 34098, Istanbul, Turkey
| | - Zafer Akman
- Department of Cardiology, Cerrahpasa School of Medicine, Cerrahpasa/Fatih, Istanbul University-Cerrahpasa, Kocamustafapasa Street, 34098, Istanbul, Turkey
| | - Adem Atici
- Department of Cardiology, Istanbul Medeniyet University, Goztepe Research and Training Hospital, Istanbul, Turkey
| | - Bilgehan Karadag
- Department of Cardiology, Cerrahpasa School of Medicine, Cerrahpasa/Fatih, Istanbul University-Cerrahpasa, Kocamustafapasa Street, 34098, Istanbul, Turkey
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Reddy RK, Howard JP, Jamil Y, Madhavan MV, Nanna MG, Lansky AJ, Leon MB, Ahmad Y. Percutaneous Coronary Revascularization Strategies After Myocardial Infarction: A Systematic Review and Network Meta-Analysis. J Am Coll Cardiol 2024; 84:276-294. [PMID: 38986670 DOI: 10.1016/j.jacc.2024.04.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 03/26/2024] [Accepted: 04/12/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Complete revascularization with percutaneous coronary intervention improves outcomes compared with culprit revascularization following myocardial infarction (MI) with multivessel coronary artery disease. An all-cause mortality reduction has never been demonstrated. Debate also remains regarding the optimal timing of complete revascularization (immediate or staged), and method of evaluation of nonculprit lesions (physiology or angiography). OBJECTIVES This study aims to perform an updated systematic review with frequentist and Bayesian network meta-analyses including the totality of randomized data investigating revascularization strategies in patients presenting with MI and multivessel coronary artery disease. METHODS The primary comparison tested complete vs culprit revascularization. Timing and methods of achieving complete revascularization were assessed. The prespecified primary outcome was all-cause mortality. Outcomes were expressed as relative risk (RR) (95% CI). RESULTS Twenty-four eligible trials randomized 16,371 patients (weighted mean follow-up: 26.4 months). Compared with culprit revascularization, complete revascularization reduced all-cause mortality in patients with any MI (RR: 0.85; 95% CI: 0.74-0.99; P = 0.04). Cardiovascular mortality, MI, major adverse cardiac events and repeat revascularization were also significantly reduced. In patients presenting with ST-segment elevation myocardial infarction, the point estimate for all-cause mortality with complete revascularization was RR: 0.91 (95% CI: 0.78-1.05; P = 0.18). Rates of stent thrombosis, major bleeding, and acute kidney injury were similar. Immediate complete revascularization ranked higher than staged complete revascularization for all endpoints. CONCLUSIONS Complete revascularization following MI reduces all-cause mortality, cardiovascular mortality, MI, major adverse cardiac events, and repeat revascularization. There may be benefits to immediate complete revascularization, but additional head-to-head trials are needed.
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Affiliation(s)
- Rohin K Reddy
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Yasser Jamil
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mahesh V Madhavan
- Division of Cardiology, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Alexandra J Lansky
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Martin B Leon
- Division of Cardiology, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Yousif Ahmad
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.
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Kim MC, Ahn JH, Hyun DY, Lim Y, Lee SH, Oh S, Cho KH, Sim DS, Hong YJ, Kim JH, Jeong MH, Cho JH, Lee SR, Kang DO, Hwang JY, Youn YJ, Jeong YH, Park Y, Kim DB, Choo EH, Kim CJ, Kim W, Rhew JY, Lee JH, Yoo SY, Ahn Y. Timing of fractional flow reserve-guided complete revascularization in patients with ST-segment elevation myocardial infarction with multivessel disease: Rationale and design of the OPTION-STEMI trial. Am Heart J 2024; 273:35-43. [PMID: 38641031 DOI: 10.1016/j.ahj.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/19/2024] [Accepted: 03/31/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Current guidelines recommend complete revascularization (CR) in hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD). With regard to the timing of percutaneous coronary intervention (PCI) for non-infarct-related artery (non-IRA), recent randomized clinical trials have revealed that immediate CR was non-inferior to staged CR. However, the optimal timing of CR remains uncertain. The OPTION-STEMI trial compared immediate CR and in-hospital staged CR guided by fractional flow reserve (FFR) for intermediate stenosis of the non-IRA. METHODS The OPTION-STEMI is a multicenter, investigator-initiated, prospective, open-label, non-inferiority randomized clinical trial. The study included patients with at least 1 non-IRA lesion with ≥50% stenosis by visual estimation. Patients fulfilling the inclusion criteria were randomized into 2 groups at a 1:1 ratio: immediate CR (i.e., PCI for the non-IRA performed during primary angioplasty) or in-hospital staged CR. In the in-hospital staged CR group, PCI for non-IRA lesions was performed on another day during the index hospitalization. Non-IRA lesions with 50%-69% stenosis by visual estimation were evaluated by FFR, whereas those with ≥70% stenosis was revascularized without FFR. The primary endpoint was the composite of all-cause death, non-fatal myocardial infarction, and all unplanned revascularization at 1 year after randomization. Enrolment began in December 2019 and was completed in January 2024. The follow-up for the primary endpoint will be completed in January 2025, and primary results will be available in the middle of 2025. CONCLUSIONS The OPTION-STEMI is a multicenter, non-inferiority, randomized trial that evaluated the timing of in-hospital CR with the aid of FFR in patients with STEMI and MVD. TRIAL REGISTRATION URL: https://www. CLINICALTRIALS gov. Unique identifier: NCT04626882; and URL: https://cris.nih.go.kr. Unique identifier: KCT0004457.
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Affiliation(s)
- Min Chul Kim
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Joon Ho Ahn
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Dae Young Hyun
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Yongwhan Lim
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Seok Oh
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Kyung Hoon Cho
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Doo Sun Sim
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Young Joon Hong
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Ju Han Kim
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Myung Ho Jeong
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | | | - Sang-Rok Lee
- Division of Cardiology, Department of Internal Medicine, Jeonbuk National University Medical School, Jeonbuk National University Hospital, Jeonju, Korea
| | - Dong Oh Kang
- Cardiovascular Center, Department of Internal Medicine, Korea University College of Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Jin-Yong Hwang
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Young Jin Youn
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, Korea
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea and Division of Cardiology, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Yongwhi Park
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Dong-Bin Kim
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea, Bucheon St. Mary's Hospital, Bucheon, Korea
| | - Eun-Ho Choo
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Chan Joon Kim
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea, Uijeongbu St. Mary's Hospital, Uijeongbu, Korea
| | - Weon Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University College of Medicine, Kyung Hee University Medical Center, Seoul, Korea
| | | | - Jung-Hee Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, Korea and Division of Cardiology, Yeungnam University College of Medicine, Yeungnam University Medical Center, Daegu, Korea
| | - Sang-Yong Yoo
- Good Morning Hospital, Pyeongtaek, Korea and Division of Cardiology, Department of Internal Medicine, University of Ulsan College of Medicine, Gangneung Asan Hospital, Gangneung, Korea
| | - Youngkeun Ahn
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea.
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Zhou YM, Sun B. Immediate Versus Staged Complete Revascularization in Patients Presenting with Acute Coronary Syndrome and Multivessel Coronary Disease Without Cardiac Shock: A Study-Level Meta-analysis of Randomized Controlled Trials. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07597-7. [PMID: 38884921 DOI: 10.1007/s10557-024-07597-7] [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] [Accepted: 06/09/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Achieving full revascularization via percutaneous coronary intervention (PCI) may enhance the prognosis of individuals diagnosed with acute coronary syndrome (ACS) and multivessel coronary disease (MVD). The present work focused on investigating whether PCI should be performed during staged or index procedures for non-culprit lesions. METHODS Electronic databases, such as PubMed, EMBASE, the Cochrane Library, and Web of Science, were systematically explored to locate studies contrasting immediate revascularization with staged complete revascularization for patients who experienced ACS and MVD without cardiac shock. The outcome measures comprised major adverse cardiovascular events (MACEs), all-cause mortality, cardiovascular mortality, myocardial infarction (MI), stroke, and unplanned ischemia-driven revascularization (UIDR). RESULTS Nine randomized controlled trials involving 3550 patients, including 1780 who received immediate complete revascularization (ICR) and 1770 who received staged complete revascularization (SCR), were included in the analysis. The ICR group had lower MACEs (RR: 0.73, 95% CI: 0.61~0.87, P = 0.0004), MI (RR: 0.53, 95% CI: 0.37~0.77, P = 0.0008), and UIDR (RR: 0.64, 95% CI: 0.50~0.81, P = 0.0003) than did the SCR group. All-cause mortality, CVD incidence, and stroke incidence did not significantly differ between the two groups. According to our subgroup analyses based on the time window of the SCR, the ICR group had significantly fewer MACEs (RR: 0.70, 95% CI: 0.56~0.88, P = 0.003), MI (RR: 0.53, 95% CI: 0.37~0.77, P = 0.0002), and UIDR (RR: 0.56, 95% CI: 0.40~0.77, P = 0.0004) than did the subgroup of patients who were between discharge and 45 days. CONCLUSION Compared with patients in the SCR group, patients in the ICR group had decreased MACEs, MI, and UIDR, especially between discharge and 45 days. All-cause mortality and CVD incidence were not significantly different between the two groups.
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Affiliation(s)
- Ye Ming Zhou
- Department of Emergency, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Bing Sun
- Department of Cardiology, Tang Du Hospital, Air Force Medical University, Xi'An, Shaanxi, China.
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Pan J, Li C, Ren Y, Liu Y, Hua C, Wang L. Infarct-related artery only revascularization versus multi-vessel revascularization for patients with Killip I-IV acute myocardial infarction and multivessel disease. Acta Cardiol 2024; 79:464-472. [PMID: 38661286 DOI: 10.1080/00015385.2024.2344331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 04/12/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND The optimal revascularization strategy for non-culprit vessels is still up for debate nowadays, particularly when it comes to individuals with different Killip classes. Therefore, the aim of our study was to investigate whether multivessel revascularization, as compared with infarct-related artery (IRA) alone revascularization, improves long-term prognosis in patients who have experienced an acute myocardial infarction (AMI) and have multivessel coronary artery disease (CAD). METHODS A retrospective analysis was conducted on clinical data from 646 patients who presented with AMI and multivessel CAD at Beijing Chaoyang hospital between November 2014 and November 2020. Based on various revascularization strategies, patients were categorised into two groups: IRA-only revascularization (n = 416) and multivessel revascularization (n = 230). The primary endpoint was cardiovascular death. RESULTS In the following 60.6 months (60.6 ± 23.9), the primary endpoint occurred in 3% of the multivessel revascularization group versus 9.6% in the IRA-only revascularization group (HR 0.284, CI 0.120-0.669, p = 0.002). For the Killip I-II patients (n = 533), the primary endpoint occurred in 2.6% of the multivessel revascularization group versus 9.5% in the IRA-only revascularization group (HR 0.236, CI 0.083-0.667, p = 0.003). For Killip III-IV patients (n = 113), there was no significance differences in the primary endpoint. After using the inverse probability weighted method, the benefit of complete revascularization was consistently observed. CONCLUSIONS Multivessel revascularization significantly reduced the incidence of cardiovascular death for patients presenting with AMI and multivessel CAD, particularly for Killip I-II patients. There were no significant differences in the primary outcome across the groups of patients with Killip III-IV.
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Affiliation(s)
- Jing Pan
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Chuang Li
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yuting Ren
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yumeng Liu
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Cuncun Hua
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Lefeng Wang
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Hlinomaz O, Motovska Z, Kala P, Hromadka M, Precek J, Mrozek J, Červinka P, Kettner J, Matejka J, Zohoor A, Bis J, Jarkovsky J. Outcomes of patients with myocardial infarction and cardiogenic shock treated with culprit vessel-only versus multivessel primary PCI. Hellenic J Cardiol 2024; 76:1-10. [PMID: 37633488 DOI: 10.1016/j.hjc.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 08/18/2023] [Accepted: 08/19/2023] [Indexed: 08/28/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES Multivessel primary percutaneous coronary intervention (pPCI) is still often used in patients with ST-elevation myocardial infarction (STEMI) and cardiogenic shock (CS). The study aimed to compare the characteristics and prognosis of patients with CS-STEMI and multivessel coronary disease (MVD) treated with culprit vessel-only pPCI or multivessel-pPCI during the initial procedure. MATERIAL AND METHODS From 2016 to 2020, 23,703 primary PCI patients with STEMI were included in a national all-comers registry of cardiovascular interventions. Of them, 1,213 (5.1%) patients had CS and MVD at admission to the hospital. Initially, 921 (75.9%) patients were treated with culprit vessel (CV)-pPCI and 292 (24.1%) with multivessel (MV)-pPCI. RESULTS Patients with 3-vessel disease and left main disease had a higher probability of being treated with MV-pPCI than patients with 2-vessel disease and patients without left main disease (28.5% vs. 18.6%; p < 0.001 and 37.7% vs. 20.6%; p < 0.001). Intra-aortic balloon pump, extracorporeal membrane oxygenation (ECMO), and other mechanical circulatory support systems were more often used in patients with MV-pPCI. Thirty (30)-day and 1-year all-cause mortality rates were similar in the CV-pPCI and MV-pPCI groups (odds ratio, 1.01; 95% confidence interval [CI] 0.77 to 1.32; p = 0.937 and 1.1; 95% CI 0.84 to 1.44; p = 0.477). The presence of 3-vessel disease and the use of ECMO were the strongest adjusted predictors of 30-day and 1-year mortality. CONCLUSIONS Our data from an extensive all-comers registry suggests that selective use of MV-pPCI does not increase the all-cause mortality rate in patients with CS-STEMI and MVD compared to CV-pPCI.
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Affiliation(s)
- Ota Hlinomaz
- International Clinical Research Center and Department of Cardioangiology, St. Anne University Hospital and Masaryk University, Brno, Czech Republic
| | - Zuzana Motovska
- Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic.
| | - Petr Kala
- University Hospital Brno and Faculty of Medicine of Masaryk University, Department of Internal Medicine and Cardiology, Brno, Czech Republic
| | - Milan Hromadka
- University Hospital and Faculty of Medicine, Pilsen, Czech Republic
| | - Jan Precek
- University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Jan Mrozek
- University Hospital and Faculty of Medicine, Ostrava, Czech Republic
| | | | - Jiri Kettner
- Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jan Matejka
- Regional Hospital, Pardubice, Czech Republic
| | | | - Josef Bis
- University Hospital and Faculty of Medicine, Hradec Kralové, Czech Republic
| | - Jiri Jarkovsky
- Institute of Biostatistics and Analyses of Masaryk University, Brno, Czech Republic; Institute of Health Information and Statistics of the Czech Republic, Czech Republic
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Hong D, Lee SH, Lee J, Lee H, Shin D, Kim HK, Park KH, Choo EH, Kim CJ, Kim MC, Hong YJ, Jeong MH, Ahn SG, Doh JH, Lee SY, Don Park S, Lee HJ, Kang MG, Koh JS, Cho YK, Nam CW, Choi KH, Park TK, Yang JH, Song YB, Choi SH, Gwon HC, Guallar E, Cho J, Hahn JY, Kang D, Lee JM. Cost-Effectiveness of Fractional Flow Reserve-Guided Treatment for Acute Myocardial Infarction and Multivessel Disease: A Prespecified Analysis of the FRAME-AMI Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2352427. [PMID: 38270954 PMCID: PMC10811558 DOI: 10.1001/jamanetworkopen.2023.52427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/14/2023] [Indexed: 01/26/2024] Open
Abstract
Importance Complete revascularization by non-infarct-related artery (IRA) percutaneous coronary intervention (PCI) in patients with acute myocardial infarction is standard practice to improve patient prognosis. However, it is unclear whether a fractional flow reserve (FFR)-guided or angiography-guided treatment strategy for non-IRA PCI would be more cost-effective. Objective To evaluate the cost-effectiveness of FFR-guided compared with angiography-guided PCI in patients with acute myocardial infarction and multivessel disease. Design, Setting, and Participants In this prespecified cost-effectiveness analysis of the FRAME-AMI randomized clinical trial, patients were randomly allocated to either FFR-guided or angiography-guided PCI for non-IRA lesions between August 19, 2016, and December 24, 2020. Patients were aged 19 years or older, had ST-segment elevation myocardial infarction (STEMI) or non-STEMI and underwent successful primary or urgent PCI, and had at least 1 non-IRA lesion (diameter stenosis >50% in a major epicardial coronary artery or major side branch with a vessel diameter of ≥2.0 mm). Data analysis was performed on August 27, 2023. Intervention Fractional flow reserve-guided vs angiography-guided PCI for non-IRA lesions. Main Outcomes and Measures The model simulated death, myocardial infarction, and repeat revascularization. Future medical costs and benefits were discounted by 4.5% per year. The main outcomes were quality-adjusted life-years (QALYs), direct medical costs, incremental cost-effectiveness ratio (ICER), and incremental net monetary benefit (INB) of FFR-guided PCI compared with angiography-guided PCI. State-transition Markov models were applied to the Korean, US, and European health care systems using medical cost (presented in US dollars), utilities data, and transition probabilities from meta-analysis of previous trials. Results The FRAME-AMI trial randomized 562 patients, with a mean (SD) age of 63.3 (11.4) years. Most patients were men (474 [84.3%]). Fractional flow reserve-guided PCI increased QALYs by 0.06 compared with angiography-guided PCI. The total cumulative cost per patient was estimated as $1208 less for FFR-guided compared with angiography-guided PCI. The ICER was -$19 484 and the INB was $3378, indicating that FFR-guided PCI was more cost-effective for patients with acute myocardial infarction and multivessel disease. Probabilistic sensitivity analysis showed consistent results and the likelihood iteration of cost-effectiveness in FFR-guided PCI was 97%. When transition probabilities from the pairwise meta-analysis of the FLOWER-MI and FRAME-AMI trials were used, FFR-guided PCI was more cost-effective than angiography-guided PCI in the Korean, US, and European health care systems, with an INB of $3910, $8557, and $2210, respectively. In probabilistic sensitivity analysis, the likelihood iteration of cost-effectiveness with FFR-guided PCI was 85%, 82%, and 31% for the Korean, US, and European health care systems, respectively. Conclusions and Relevance This cost-effectiveness analysis suggests that FFR-guided PCI for non-IRA lesions saved medical costs and increased quality of life better than angiography-guided PCI for patients with acute myocardial infarction and multivessel disease. Fractional flow reserve-guided PCI should be considered in determining the treatment strategy for non-IRA stenoses in these patients. Trial Registration ClinicalTrials.gov Identifier: NCT02715518.
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Affiliation(s)
- David Hong
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Hun Lee
- Chonnam National University Hospital, Gwangju, Korea
| | - Jin Lee
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
| | - Hankil Lee
- College of Pharmacy, Ajou University, Suwon, South Korea
| | - Doosup Shin
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina
| | - Hyun Kuk Kim
- Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea
| | - Keun Ho Park
- Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea
| | - Eun Ho Choo
- Seoul St Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Chan Joon Kim
- Uijeongbu St Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Min Chul Kim
- Chonnam National University Hospital, Gwangju, Korea
| | | | | | - Sung Gyun Ahn
- Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Sang Yeub Lee
- Chung-Ang University College of Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea
| | | | | | - Min Gyu Kang
- Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Jin-Sin Koh
- Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Yun-Kyeong Cho
- Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Chang-Wook Nam
- Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Ki Hong Choi
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Taek Kyu Park
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Hoon Yang
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Bin Song
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Hyuk Choi
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeon-Cheol Gwon
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eliseo Guallar
- Department of Epidemiology and Medicine, Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Juhee Cho
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
| | - Joo-Yong Hahn
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Danbee Kang
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
| | - Joo Myung Lee
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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8
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Bujak K, Rinaldi R, Vidal-Cales P, Montone RA, Diletti R, Gąsior M, Crea F, Sabaté M, Brugaletta S. Immediate versus staged complete revascularization in acute coronary syndrome: A meta-analysis of randomized controlled trials. Int J Cardiol 2023; 393:131397. [PMID: 37769973 DOI: 10.1016/j.ijcard.2023.131397] [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] [Received: 06/27/2023] [Revised: 09/11/2023] [Accepted: 09/24/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Clinical guidelines recommend a complete revascularization (CR) in patients with acute coronary syndromes (ACS) and multivessel disease (MVD). However, its optimal timing is unclear. The aim of this meta-analysis was to compare the clinical outcomes following immediate versus staged CR in ACS. METHODS PubMed and Scopus were searched until March 2023 for randomized controlled trials (RCTs) comparing immediate versus staged CR. The primary endpoint was major adverse cardiovascular event (MACE) at the longest follow-up. Secondary outcomes were all-cause death, cardiovascular death, myocardial infarction (MI), any unplanned revascularization, target-vessel revascularization (TVR), and stent thrombosis. Safety outcomes were major bleeding, contrast volume, procedure duration, and length of hospitalization. RESULTS Eight RCTs were included (3559 patients, weighted mean follow-up 12.5 months). There were no differences in the primary endpoint (OR 0.74, 95%CI: 0.54-1.01) and in the secondary endpoints of death, and stent thrombosis between the two CR strategies. Immediate CR was associated with a lower risk of recurrent MI (OR 0.51, 95% CI 0.34-0.76), any unplanned revascularization (OR 0.59, 95%CI: 0.43-0.80), and TVR (OR 0.61, 95% CI 0.45-0.84) compared to staged CR. Immediate CR was also associated with lower total contrast volume and shorter total procedure duration and hospitalization length compared to staged CR without differences in major bleedings. CONCLUSION No difference was found between immediate and staged CR regarding MACE, or deaths rates at one year. Immediate CR may be associated with a lower risk of recurrent MI and unplanned coronary revascularization than staged CR.
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Affiliation(s)
- Kamil Bujak
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; 3rd Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Riccardo Rinaldi
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Pablo Vidal-Cales
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Rocco Antonio Montone
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Roberto Diletti
- Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Mariusz Gąsior
- 3rd Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Filippo Crea
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Manel Sabaté
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Salvatore Brugaletta
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
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9
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Faro DC, Laudani C, Agnello FG, Ammirabile N, Finocchiaro S, Legnazzi M, Mauro MS, Mazzone PM, Occhipinti G, Rochira C, Scalia L, Spagnolo M, Greco A, Capodanno D. Complete Percutaneous Coronary Revascularization in Acute Coronary Syndromes With Multivessel Coronary Disease: A Systematic Review. JACC Cardiovasc Interv 2023; 16:2347-2364. [PMID: 37821180 DOI: 10.1016/j.jcin.2023.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 06/06/2023] [Accepted: 07/18/2023] [Indexed: 10/13/2023]
Abstract
Multivessel disease (MVD) affects approximately 50% of patients with acute coronary syndromes (ACS) and is significantly burdened by poor outcomes and high mortality. It represents a clinical challenge in patient management and decision making and subtends an evolving research area related to the pathophysiology of unstable plaques and local or systemic inflammation. The benefits of complete revascularization are established in hemodynamically stable ACS patients with MVD, and guidelines provide some reference points to inform clinical practice, based on an evidence level that is solid for ST-segment elevation myocardial infarction and less robust for non-ST-segment elevation myocardial infarction and cardiogenic shock. However, several areas of uncertainty remain, such as the optimal timing for complete revascularization or the best guiding strategy for intermediate stenoses. We performed a systematic review of current evidence in the field of percutaneous revascularization in ACS and MVD, also including future perspectives from ongoing trials that will directly compare different timing strategies and investigate the role of invasive and noninvasive guidance techniques. (Complete percutaneous coronary revascularization in patients with acute myocardial infarction and multivessel disease; CRD42022383123).
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Affiliation(s)
- Denise Cristiana Faro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Federica Giuseppa Agnello
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Nicola Ammirabile
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Marco Legnazzi
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Carla Rochira
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Lorenzo Scalia
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Marco Spagnolo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy.
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10
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Yasuda K, Ogita M, Tsuboi S, Nishio R, Takeuchi M, Sonoda T, Wada H, Suwa S, Miyauchi K, Daida H, Minamino T. Impact of Multivessel Percutaneous Coronary Intervention vs. Culprit Vessel Percutaneous Coronary Intervention in Patients with Acute Coronary Syndromes and Multivessel Coronary Artery Disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 53:38-44. [PMID: 36890057 DOI: 10.1016/j.carrev.2023.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 02/23/2023] [Accepted: 02/23/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Recent clinical trials have shown that percutaneous coronary intervention (PCI) for non-culprit lesions (NCLs) reduces the risk of adverse events in patients with ST-segment elevation myocardial infarction (STEMI), but the effect on long-term outcomes remains unclear in acute coronary syndrome (ACS) patients and a real-world clinical setting. METHODS A retrospective observational cohort study of ACS patients who underwent primary PCI between April 2004 and December 2017 at Juntendo University Shizuoka Hospital, Japan, was performed. The primary endpoint was the composite of cardiovascular disease death (CVD death) and non-fatal myocardial infarction (MI) during the mean follow-up period of 2.7 years, and a landmark analysis for the incidence of the primary endpoint from 31 days to 5 years between the multivessel PCI group and the culprit only PCI group was performed. Multivessel PCI was defined as PCI including non-infarct-related coronary arteries within 30 days after the onset of ACS. RESULTS Of the 1109 ACS patients with multivessel coronary artery disease of the current cohort, multivessel PCI was performed in 364 (33.2 %) patients. The incidence of the primary endpoint from 31 days to 5 years was significantly lower in the multivessel PCI group (4.0 % vs. 9.6 %, log-rank p = 0.0008). Multivariate Cox regression analysis showed that multivessel PCI was significantly associated with fewer cardiovascular events (HR 0.37, 95 % CI 0.19-0.67, p = 0.0008). CONCLUSION In ACS patients with multivessel coronary artery disease, multivessel PCI may reduce the risk of CVD death and non-fatal MI compared to culprit-lesion-only PCI.
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Affiliation(s)
- Kentaro Yasuda
- Department of Cardiovascular Medicine, Juntendo University Shizuoka Hospital, Japan
| | - Manabu Ogita
- Department of Cardiovascular Medicine, Juntendo University Shizuoka Hospital, Japan.
| | - Shuta Tsuboi
- Department of Cardiovascular Medicine, Juntendo University Shizuoka Hospital, Japan
| | - Ryota Nishio
- Department of Cardiovascular Medicine, Juntendo University Shizuoka Hospital, Japan
| | - Mitsuhiro Takeuchi
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Taketo Sonoda
- Department of Cardiovascular Medicine, Juntendo University Shizuoka Hospital, Japan
| | - Hideki Wada
- Department of Cardiovascular Medicine, Juntendo University Shizuoka Hospital, Japan
| | - Satoru Suwa
- Department of Cardiovascular Medicine, Juntendo University Shizuoka Hospital, Japan
| | - Katsumi Miyauchi
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Hiroyuki Daida
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Tohru Minamino
- Department of Cardiovascular Medicine, Juntendo University Shizuoka Hospital, Japan; Japan Agency for Medical Research and Development-Core Research for Evolutionary Medical Science and Technology (AMED-CREST), Japan Agency for Medical Research and Development, Japan
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11
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Diletti R, den Dekker WK, Bennett J, Schotborgh CE, van der Schaaf R, Sabaté M, Moreno R, Ameloot K, van Bommel R, Forlani D, van Reet B, Esposito G, Dirksen MT, Ruifrok WPT, Everaert BRC, Van Mieghem C, Elscot JJ, Cummins P, Lenzen M, Brugaletta S, Boersma E, Van Mieghem NM. Immediate versus staged complete revascularisation in patients presenting with acute coronary syndrome and multivessel coronary disease (BIOVASC): a prospective, open-label, non-inferiority, randomised trial. Lancet 2023; 401:1172-1182. [PMID: 36889333 DOI: 10.1016/s0140-6736(23)00351-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND In patients with acute coronary syndrome and multivessel coronary disease, complete revascularisation by percutaneous coronary intervention (PCI) is associated with improved clinical outcomes. We aimed to investigate whether PCI for non-culprit lesions should be attempted during the index procedure or staged. METHODS This prospective, open-label, non-inferiority, randomised trial was done at 29 hospitals across Belgium, Italy, the Netherlands, and Spain. We included patients aged 18-85 years presenting with ST-segment elevation myocardial infarction or non-ST-segment elevation acute coronary syndrome and multivessel (ie, two or more coronary arteries with a diameter of 2·5 mm or more and ≥70% stenosis based on visual estimation or positive coronary physiology testing) coronary artery disease with a clearly identifiable culprit lesion. A web-based randomisation module was used to randomly assign patients (1:1), with a random block size of four to eight, stratified by study centre, to undergo immediate complete revascularisation (PCI of the culprit lesion first, followed by other non-culprit lesions deemed to be clinically significant by the operator during the index procedure) or staged complete revascularisation (PCI of only the culprit lesion during the index procedure and PCI of all non-culprit lesions deemed to be clinically significant by the operator within 6 weeks after the index procedure). The primary outcome was the composite of all-cause mortality, myocardial infarction, any unplanned ischaemia-driven revascularisation, or cerebrovascular events at 1 year after the index procedure. Secondary outcomes included all-cause mortality, myocardial infarction, and unplanned ischaemia-driven revascularisation at 1 year after the index procedure. Primary and secondary outcomes were assessed in all randomly assigned patients by intention to treat. Non-inferiority of immediate to staged complete revascularisation was considered to be met if the upper boundary of the 95% CI of the hazard ratio (HR) for the primary outcome did not exceed 1·39. This trial is registered with ClinicalTrials.gov, NCT03621501. FINDINGS Between June 26, 2018, and Oct 21, 2021, 764 patients (median age 65·7 years [IQR 57·2-72·9] and 598 [78·3%] males) were randomly assigned to the immediate complete revascularisation group and 761 patients (median age 65·3 years [58·6-72·9] and 589 [77·4%] males) were randomly assigned to the staged complete revascularisation group, and were included in the intention-to-treat population. The primary outcome at 1 year occurred in 57 (7·6%) of 764 patients in the immediate complete revascularisation group and in 71 (9·4%) of 761 patients in the staged complete revascularisation group (HR 0·78, 95% CI 0·55-1·11, pnon-inferiority=0·0011). There was no difference in all-cause death between the immediate and staged complete revascularisation groups (14 [1·9%] vs nine [1·2%]; HR 1·56, 95% CI 0·68-3·61, p=0·30). Myocardial infarction occurred in 14 (1·9%) patients in the immediate complete revascularisation group and in 34 (4·5%) patients in the staged complete revascularisation group (HR 0·41, 95% CI 0·22-0·76, p=0·0045). More unplanned ischaemia-driven revascularisations were performed in the staged complete revascularisation group than in the immediate complete revascularisation group (50 [6·7%] patients vs 31 [4·2%] patients; HR 0·61, 95% CI 0·39-0·95, p=0·030). INTERPRETATION In patients presenting with acute coronary syndrome and multivessel disease, immediate complete revascularisation was non-inferior to staged complete revascularisation for the primary composite outcome and was associated with a reduction in myocardial infarction and unplanned ischaemia-driven revascularisation. FUNDING Erasmus University Medical Center and Biotronik.
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Affiliation(s)
- Roberto Diletti
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Wijnand K den Dekker
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Johan Bennett
- Department of Cardiovascular Medicine, University Hospital Leuven, Leuven, Belgium
| | | | - Rene van der Schaaf
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Manel Sabaté
- Interventional Cardiology Department, Hospital Clinic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Raúl Moreno
- Interventional Cardiology Unit, Cardiology Department, La Paz University Hospital, Madrid, Spain
| | - Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos, Genk, Belgium
| | | | - Daniele Forlani
- Department of Cardiology, Santo Spirito Hospital, Pescara, Italy
| | - Bert van Reet
- Department of Cardiology, AZ Turnhout, Turnhout, Belgium
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Maurits T Dirksen
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, Netherlands
| | | | | | | | - Jacob J Elscot
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Paul Cummins
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Mattie Lenzen
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Salvatore Brugaletta
- Interventional Cardiology Department, Hospital Clinic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Eric Boersma
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Nicolas M Van Mieghem
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, Netherlands.
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12
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Rumiz E, Vilar JV, Cubillos A, Valero E, Berenguer A, Fácila L, Vidal V, Fernandez C, Llopis G, Paya R, Nuñez J. Long-term recurrent events in ST-elevation myocardial infarction and multivessel disease. The impact of different revascularization strategies. Rev Port Cardiol 2023; 42:445-451. [PMID: 36706913 DOI: 10.1016/j.repc.2023.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/22/2022] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION The benefit of complete revascularization (CR) on long-term total event reduction in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD), still remains unclear. We assessed the efficacy of three different revascularization strategies on long-term total recurrent events. METHODS We retrospectively analyzed 414 consecutive patients admitted with STEMI and MVD who were categorized according to the revascularization strategy used: culprit-vessel-only percutaneous coronary intervention (PCI) (n=163); in-hospital CR (n=136); and delayed CR (n=115). The combined endpoint assessed was all-cause mortality, the total number of myocardial infarctions, ischemia-driven revascularizations or strokes. Negative binomial regression was used to assess the association between the revascularization strategy and total events; risk estimates were expressed as an incidence rates ratio (IRR). RESULTS At a median follow-up of four years (1.2-6), rates of the combined endpoint per 10 patient-years were 18, 0.8, and 0.6 in culprit-vessel-only PCI, in-hospital CR, and delayed CR strategies, respectively (p<0.001). After multivariable adjustment and when compared with culprit-vessel-only PCI, both in-hospital and delayed CR strategies were significantly associated with a reduction in the combined endpoint (IRR=0.40: 95% confidence interval (CI), 0.25-0.64; p<0.001; and IRR 0.40: 95% CI, 0.24-0.62; p<0.001, respectively). No differences were observed across in-hospital and delayed CR strategies. CONCLUSIONS Complete revascularization of non-culprit lesions in patients with STEMI and MVD reduces the risk of total recurrent events during long-term follow-up. No differences between in-hospital and delayed CR strategies were found.
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Affiliation(s)
- Eva Rumiz
- Cardiology Department, Consorcio Hospital General Universitario de Valencia, Valencia, Spain; Cardiology Department, Hospital Quiron Salud Valencia, Valencia, Spain; Universitat Jaume I, Spain.
| | - Juan Vicente Vilar
- Cardiology Department, Consorcio Hospital General Universitario de Valencia, Valencia, Spain; Cardiology Department, Hospital Quiron Salud Valencia, Valencia, Spain
| | - Andrés Cubillos
- Cardiology Department, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Ernesto Valero
- Cardiology Department, Hospital Quiron Salud Valencia, Valencia, Spain; Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Spain
| | - Alberto Berenguer
- Cardiology Department, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Lorenzo Fácila
- Cardiology Department, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Verónica Vidal
- Cardiology Department, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Carmen Fernandez
- Cardiology Department, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Guillem Llopis
- Cardiology Department, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Rafael Paya
- Cardiology Department, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Julio Nuñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Spain
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13
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Feng Y, Li S, Hu S, Wan J, Shao H. The optimal timing for non-culprit percutaneous coronary intervention in patients with multivessel coronary artery disease: A pairwise and network meta-analysis of randomized trials. Front Cardiovasc Med 2022; 9:1000664. [PMID: 36225962 PMCID: PMC9548605 DOI: 10.3389/fcvm.2022.1000664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
Background and aimsRecently, several randomized trials have shown that patients with multivessel disease (MVD) often pursue complete revascularization during percutaneous coronary intervention (PCI) to improve their prognosis. However, the optimal time for the non-culprit artery has been controversial. This study aimed to determine the optimal strategy for revascularization in ST-segment elevation myocardial infarction (STEMI) patients with multivessel coronary artery disease (CAD).MethodsRandomized controlled trials (RCTs) comparing three revascularization strategies [i.e., complete revascularization at the index procedure (CR), complete revascularization as a staged procedure (SR), or culprit-only revascularization (COR)] in STEMI patients with multivessel coronary artery disease were included. We performed both pairwise and network meta-analyses. Network meta-analysis was performed using mixed treatment comparison models.Results17 trials with 8568 patients were included. In the network meta-analysis, the most interesting finding was that staged revascularization increased the risk of major adverse cardiac events (MACE) compared with complete revascularization at the index procedure [odds ratio (OR): 1.93; 95% confidence interval (CI): 1.07–3.49]. In the pairwise meta-analysis, complete revascularization reduced the incidence of MACE [risk ratio (RR): 0.62, 95% CI: 0.48–0.79, p < 0.001], mainly because it reduced the probability of unplanned repeat revascularization (RR: 0.49, 95% CI: 0.33–0.75, p = 0.001). There were no significant differences in all-cause mortality, cardiac mortality, or nonfatal re-myocardial infarction (MI).ConclusionOur analysis suggests that complete revascularization should be performed in STEMI patients with multivessel coronary artery disease, and complete revascularization at the index procedure is superior to staged revascularization in reducing the risk of MACE events.
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Affiliation(s)
- Yujia Feng
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Shu Li
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Sihan Hu
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jing Wan
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China
- *Correspondence: Jing Wan
| | - Hua Shao
- Department of Clinical Laboratory, Remin Hospital of Wuhan University, Wuhan, China
- Hua Shao
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14
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Towashiraporn K. Current recommendations for revascularization of non-infarct-related artery in patients presenting with ST-segment elevation myocardial infarction and multivessel disease. Front Cardiovasc Med 2022; 9:969060. [PMID: 36035910 PMCID: PMC9402999 DOI: 10.3389/fcvm.2022.969060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/25/2022] [Indexed: 11/22/2022] Open
Abstract
ST-segment elevation myocardial infarction (STEMI) is a leading cause of morbidity and mortality worldwide. Immediate reperfusion therapy of the infarct-related artery (IRA) is the mainstay of treatment, either via primary percutaneous coronary intervention (PPCI) or thrombolytic therapy when PPCI is not feasible. Several studies have reported the incidence of multivessel disease (MVD) to be about 50% of total STEMI cases. This means that after successful PPCI of the IRA, residual lesion(s) of the non-IRA may persist. Unlike the atherosclerotic plaque of stable coronary artery disease, the residual obstructive lesion of the non-IRA contains a significantly higher prevalence of vulnerable plaques. Since these lesions are a strong predictor of acute coronary syndrome, if left untreated they are a possible cause of future adverse cardiovascular events. Percutaneous coronary intervention (PCI) of the obstructive lesion of the non-IRA to achieve complete revascularization (CR) is therefore preferable. Several major randomized controlled trials (RCTs) and meta-analyses demonstrated the clinical benefits of the CR strategy in the setting of STEMI with MVD, not only for enhancing survival but also for reducing unplanned revascularization. The CR strategy is now supported by recently published clinical practice guidelines. Nevertheless, the benefit of revascularization must be weighed against the risks from additional procedures.
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15
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Fitzgerald S, Thiele H. Primary and Rescue PCI in STEMI. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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16
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Flores CH, Díez-Delhoyo F, Sanz-Ruiz R, Vázquez-Álvarez ME, Tamargo Delpon M, Soriano Triguero J, Elízaga Corrales J, Fernández-Avilés F, Gutiérrez Ibañes E. Microvascular dysfunction of the non-culprit circulation predicts poor prognosis in patients with ST-segment elevation myocardial infarction. IJC HEART & VASCULATURE 2022; 39:100997. [PMID: 35310375 PMCID: PMC8927849 DOI: 10.1016/j.ijcha.2022.100997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
Abstract
Microvascular and endothelial dysfunction is present in the non-culprit territory in up to 93% of patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease. Whether an impaired coronary physiology in the non-culprit territory correlates with long-term prognosis is yet to be determined. At a median follow-up of 4 years, we found that cardiovascular events and death occurred more frequently in patients with a low coronary flow reserve (CFR) in the non-culprit artery. Other parameters such as the index of microvascular resistance (IMR) or endothelial dysfunction were not independent predictors of adverse outcomes.
Background Endothelial and microvascular dysfunction are frequently found in the non-culprit territory in patients with acute myocardial infarction (AMI). We aimed to determine whether an impaired coronary physiology of the non-culprit territory impacts long-term prognosis. Methods FISIOIAM was an observational single-center study which included patients with AMI and another coronary artery lesion in a different territory. Intracoronary physiology of the non-culprit artery was analyzed early after primary percutaneous coronary intervention of the culprit artery, using fractional flow reserve (FFR), index of microcirculatory resistance (IMR), coronary flow reserve (CFR), endothelium-dependent CFR (eCFR) and macrovascular endothelial function . Patients were followed for a composite outcome of cardiovascular death, non-fatal myocardial infarction, coronary revascularization, and hospitalization due to heart failure or unstable angina. Results A total of 84 patients (mean age: 62 ± 10 years) were included and functional abnormalities were detected in 93% of them. During follow-up (median of 1422 days; interquartile range, 1287–1634), 13.1% of the patients experienced at least one adverse cardiovascular event. Kaplan-Meier analysis revealed that patients with a CFR < 2 had a higher risk of events (Hazard Ratio, HR: 4.97, 95% Confidence Interval, CI, 1.32–18.75), whereas other parameters such as FFR, IMR, eCFR, and macrovascular endothelial function had no effect. A low CFR was an independent predictor of cardiovascular events, even after adjustment for age and traditional cardiovascular risk factors (adjusted HR: 6.62, 95% CI, 1.30–33.70). Conclusions The presence of abnormal coronary microvascular function as measured by a CFR < 2 in the non-culprit territory predicts future risk of adverse cardiovascular events.
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Shin D, Rhee TM, Lee SH, Lee JM. Revascularization Strategies in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Disease: Is FFR-Guided Strategy Still Valuable? Korean Circ J 2022; 52:280-287. [PMID: 35388996 PMCID: PMC8989788 DOI: 10.4070/kcj.2021.0416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/16/2022] [Accepted: 03/10/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- Doosup Shin
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Tae-Min Rhee
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Heart Center, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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18
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Zhang P. Fasting Blood Glucose but not TMAO is Associated with In-Stent Restenosis in Patients with Acute Coronary Syndrome. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2022. [DOI: 10.15212/cvia.2021.0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: The purpose of our study was to assess whether the occurrence of ISR might be associated with plasmaTMAO levels in patients with ACS after DES implantation.Methods: This was a single center retrospective case-control study, in which 64 symptomatic patients with repeatedcoronary angiography after PCI and 15 patients with ISR were included in the ISR group, and 49 patients without ISRwere included in the non-ISR group. High-performance liquid chromatography with tandem mass spectrometry wasused to measure plasma TMAO levels.Results: No significant differences were observed in plasma TMAO between the ISR and non-ISR groups. Plasma TMAO levels showed no significant correlation with ISR, but were significantly positively correlated with diabetes mellitus, serum HbA1c levels and serum creatinine levels; moreover, they were significantly negatively correlated with female sex. ISR was significantly positively correlated with diabetes mellitus, fasting blood glucose levels, the neutrophil to lymphocyte ratio and syntax score; in addition, it was significantly negatively correlated with platelets. Logistic regression analysis indicated that fasting blood glucose was the only independent predictor of ISR.Conclusion: Plasma TMAO may not be associated with ISR and plaque burden in patients with ACS after DES implantation,whereas FBG may predict the development of ISR in these patients.
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19
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Zhao L, Guo W, Huang W, Wang L, Mo F, Chen X, Li C, Huang S. Comparative Effectiveness of Complete Revascularization Strategies in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Disease: A Bayesian Network Meta-Analysis. Front Cardiovasc Med 2021; 8:724274. [PMID: 34631826 PMCID: PMC8496298 DOI: 10.3389/fcvm.2021.724274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 08/10/2021] [Indexed: 11/30/2022] Open
Abstract
Whether fractional flow reserve (FFR) should be available for revascularization in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) is controversial. We aimed to compare the efficacy of various complete revascularization (CR) regimens for STEMI patients with MVD. The PubMed and Cochrane Library databases and clinicaltrial.gov were searched for the randomized controlled trials (RCTs) comparing the FFR-guided CR, angiography-guided CR, and culprit-only revascularization (COR) strategies in STEMI patients with MVD. A Bayesian random-effect model was employed to synthesize the evidence in network meta-analysis. We used relative risk (RR) and 95% credible interval (CrI) as measures of effect size. The primary endpoint was the composite outcome of all-cause mortality or myocardial infarction (MI). Twelve RCTs were included. Angiography-guided CR showed a lower event rate of the composite outcome (RR, 0.68; 95%CrI, 0.50–0.87), all-cause mortality (RR, 0.75; 95%CrI, 0.55–0.96), MI (RR, 0.63; 95%CrI, 0.43–0.86), and repeat revascularization (RR, 0.36; 95% CrI, 0.24–0.55) compared with COR. Additionally, angiography-guided CR had a lower risk of primary outcome (RR, 0.64; 95%CrI, 0.38–0.94) and MI (RR, 0.58; 95%CrI, 0.31–0.92) than FFR-guided CR. The difference between the FFR-guided CR and COR in terms of composite outcome, all-cause mortality, and MI was similar. Angiography-guided CR was associated with the highest probability of optimal treatment for the primary outcome (98.5%), followed by FFR-guided CR (1.2%) and COR (0.3%). STEMI patients with MVD benefitted more from angiography-guided CR than from FFR-guided CR. However, only one study compared the effectiveness of FFR-guided and angiography-guided PCI; thus, the comparison between FFR-guided and angiography-guided PCI relied on indirect evidence. Therefore, further studies directly comparing the effectiveness of these two CR strategies are warranted.
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Affiliation(s)
- Lingyue Zhao
- Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Wenqin Guo
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, China
| | - Weichao Huang
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, China
| | - Lili Wang
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, China
| | - Fanrui Mo
- Department of Cardiology, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China
| | - Xiehui Chen
- Department of Cardiology, Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Chaoyang Li
- Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Siquan Huang
- People's Hospital of Longhua District, Shenzhen, China
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20
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Mahmoudi M, Curzen N. Treatment of non-culprit lesions in STEMI: An incomplete journey. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 39:114-116. [PMID: 34531150 DOI: 10.1016/j.carrev.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/05/2021] [Accepted: 09/09/2021] [Indexed: 11/29/2022]
Abstract
Approximately 50% of patients presenting with an acute ST-segment elevation myocardial infarction (STEMI) have multivessel coronary artery disease (CAD). A number of randomized studies (Table 1) have all shown that complete revascularization (CR), either at the time of primary percutaneous coronary revascularization (PPCI) or within 45 days of the index admission, is safe and reduces the risk of repeat coronary revascularization and myocardial infarction (MI), particularly in the non-infarct related artery (NIRA). Despite consistently showing clinical benefit for CR, the results from the trials show variations in what drives this effect. Specifically, no study to date has provided a mechanistic insight as to how complete revascularization of chronic bystander disease may lead to the observed clinical benefit. Indeed, the randomized studies, through the variable nature of their results (reduction in MI versus revascularization etc.), have suggested the possibility that there are differing mechanisms for the observed benefit. In this review, we summarize the evidence base, highlight the limitations, and make the case that we need to understand the mechanism(s) underpinning the advantage of revascularization of NIRA in order to establish which patients are most likely to benefit. Without this insight, the current "one size fits all" approach may lead us in the wrong direction.
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Affiliation(s)
| | - Nick Curzen
- Faculty of Medicine, University of Southampton, UK
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21
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Serruys PW, Ono M, Garg S, Hara H, Kawashima H, Pompilio G, Andreini D, Holmes DR, Onuma Y, King Iii SB. Percutaneous Coronary Revascularization: JACC Historical Breakthroughs in Perspective. J Am Coll Cardiol 2021; 78:384-407. [PMID: 34294273 DOI: 10.1016/j.jacc.2021.05.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/05/2021] [Accepted: 05/11/2021] [Indexed: 01/09/2023]
Abstract
Over the last 4 decades, percutaneous coronary intervention has evolved dramatically and is now an acceptable treatment option for patients with advanced coronary artery disease. However, trialists have struggled to establish the respective roles for percutaneous coronary intervention and coronary artery bypass graft surgery, especially in patients with multivessel disease and unprotected left-main stem coronary artery disease. Several pivotal trials and meta-analyses comparing these 2 revascularization strategies have enabled the relative merits of each technique to be established with regard to the type of ischemic syndrome, the coronary anatomy, and the patient's overall comorbidity. Precision medicine with individualized prognosis is emerging as an important method of selecting treatment. However, the never-ending advancement of technology, in conjunction with the emergence of novel pharmacological agents, will in the future continue to force us to reconsider the evolving question: "Which treatment strategy is better and for which patient?"
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Affiliation(s)
- Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland; CÚRAM-SFI Centre for Research in Medical Devices, Galway, Ireland; NHLI, Imperial College London, London, United Kingdom.
| | - Masafumi Ono
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland; CÚRAM-SFI Centre for Research in Medical Devices, Galway, Ireland; Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Scot Garg
- Department of Cardiology, Royal Blackburn Hospital, Blackburn, United Kingdom
| | - Hironori Hara
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland; CÚRAM-SFI Centre for Research in Medical Devices, Galway, Ireland; Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Hideyuki Kawashima
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland; CÚRAM-SFI Centre for Research in Medical Devices, Galway, Ireland; Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Giulio Pompilio
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Daniele Andreini
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland; CÚRAM-SFI Centre for Research in Medical Devices, Galway, Ireland
| | - Spencer B King Iii
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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22
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Musto C, Nusca A, Biondi-Zoccai G, DE Felice F, Scappaticci M, Nazzaro MS, Viscusi MM, Ceccacci A, Versaci F. Instantaneous wave-free ratio-guided revascularization of non-culprit lesion in patients with ST-segment elevation myocardial infarction and multivessel coronary disease: design and rationale of the WAVE Registry. Minerva Cardiol Angiol 2021; 69:291-298. [PMID: 33427419 DOI: 10.23736/s2724-5683.20.05229-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Carmine Musto
- Interventional Cardiology Unit, San Camillo Hospital, Rome, Italy -
| | - Annunziata Nusca
- Cardiac Sciences Unit, Campus Bio-Medico University, Rome, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
- Mediterranea Cardiocentro, Naples, Italy
| | | | - Massimiliano Scappaticci
- Coronary Intensive Care Unit, Department of Cardiology and Hemodynamics, Santa Maria Goretti Hospital, Latina, Italy
| | - Marco S Nazzaro
- Interventional Cardiology Unit, San Camillo Hospital, Rome, Italy
| | | | - Andrea Ceccacci
- Interventional Cardiology Unit, San Camillo Hospital, Rome, Italy
| | - Francesco Versaci
- Mediterranea Cardiocentro, Naples, Italy
- Coronary Intensive Care Unit, Department of Cardiology and Hemodynamics, Santa Maria Goretti Hospital, Latina, Italy
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23
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Wu X, Ono M, Kawashima H, Poon EKW, Torii R, Shahzad A, Gao C, Wang R, Barlis P, von Birgelen C, Reiber JHC, Bourantas CV, Tu S, Wijns W, Serruys PW, Onuma Y. Angiography-Based 4-Dimensional Superficial Wall Strain and Stress: A New Diagnostic Tool in the Catheterization Laboratory. Front Cardiovasc Med 2021; 8:667310. [PMID: 34222366 PMCID: PMC8249568 DOI: 10.3389/fcvm.2021.667310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 05/21/2021] [Indexed: 12/23/2022] Open
Abstract
A novel method for four-dimensional superficial wall strain and stress (4D-SWS) is derived from the arterial motion as pictured by invasive coronary angiography. Compared with the conventional finite element analysis of cardiovascular biomechanics using the estimated pulsatile pressure, the 4D-SWS approach can calculate the dynamic mechanical state of the superficial wall in vivo, which could be directly linked with plaque rupture or stent fracture. The validation of this approach using in silico models showed that the distribution and maximum values of superficial wall stress were similar to those calculated by conventional finite element analysis. The in vivo deformation was validated on 16 coronary arteries, from the comparison of centerlines predicted by the 4D-SWS approach against the actual centerlines reconstructed from angiograms at a randomly selected time-point, which demonstrated a good agreement of the centerline morphology between both approaches (scaling: 0.995 ± 0.018 and dissimilarity: 0.007 ± 0.014). The in silico vessel models with softer plaque and larger plaque burden presented more variation in mean lumen diameter and resulted in higher superficial wall stress. In more than half of the patients (n = 16), the maximum superficial wall stress was found at the proximal lesion shoulder. Additionally, in three patients who later suffered from acute coronary syndrome, the culprit plaque rupture sites co-localized with the site of highest superficial wall stress on their baseline angiography. These representative cases suggest that angiography-based superficial wall dynamics have the potential to identify coronary segments at high-risk of plaque rupture and fracture sites of implanted stents. Ongoing studies are focusing on identifying weak spots in coronary bypass grafts, and on exploring the biomechanical mechanisms of coronary arterial remodeling and aneurysm formation. Future developments involve integration of fast computational techniques to allow online availability of superficial wall strain and stress in the catheterization laboratory.
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Affiliation(s)
- Xinlei Wu
- Institute of Cardiovascular Development and Translational Medicine, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.,Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland.,Smart Sensors Lab, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Masafumi Ono
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland.,Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Hideyuki Kawashima
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland.,Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Eric K W Poon
- Department of Medicine, Melbourne Medical School, St Vincent's Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Ryo Torii
- Department of Mechanical Engineering, University College London, London, United Kingdom
| | - Atif Shahzad
- Smart Sensors Lab, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Chao Gao
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland.,Department of Cardiology, Xijing Hospital, Xi'an, China
| | - Rutao Wang
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland.,Department of Cardiology, Xijing Hospital, Xi'an, China
| | - Peter Barlis
- Department of Medicine, Melbourne Medical School, St Vincent's Hospital, University of Melbourne, Melbourne, VIC, Australia.,Faculty of Medicine, Dentistry Health Sciences, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Clemens von Birgelen
- Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, Netherlands.,Department of Health Technology and Services Research, Technical Medical Centre, Faculty of Behavioural, Management, and Social Sciences, University of Twente, Enschede, Netherlands
| | - Johan H C Reiber
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Christos V Bourantas
- Institute of Cardiovascular Science, University College London, London, United Kingdom.,Department of Cardiology, Barts Heart Centre, London, United Kingdom
| | - Shengxian Tu
- School of Biomedical Engineering, Biomedical Instrument Institute, Shanghai Jiao Tong University, Shanghai, China
| | - William Wijns
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland.,Smart Sensors Lab, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland.,Imperial College London, National Heart and Lung Institute, London, United Kingdom
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
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24
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Soares GP. Analysis of Revascularization Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock - Results from the Portuguese Registry on Acute Coronary Syndromes. Arq Bras Cardiol 2021; 116:877-878. [PMID: 34008806 PMCID: PMC8121471 DOI: 10.36660/abc.20210127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Gabriel Porto Soares
- Universidade Federal do Rio de JaneiroRio de JaneiroRJBrasilUniversidade Federal do Rio de Janeiro, Rio de Janeiro, RJ – Brasil.
- Universidade de VassourasVassourasRJBrasilUniversidade de Vassouras, Vassouras, RJ – Brasil.
- Centro Universitário de ValençaVassourasRJBrasilCentro Universitário de Valença, Valença, RJ – Brasil.
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25
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Iglesias JF, Muller O, Losdat S, Roffi M, Kurz DJ, Weilenmann D, Kaiser C, Heg D, Valgimigli M, Windecker S, Pilgrim T. Multivessel percutaneous coronary intervention with thin-strut biodegradable versus durable polymer drug-eluting stents in ST-segment elevation myocardial infarction: A subgroup analysis of the BIOSTEMI randomized trial. Int J Cardiol 2021; 334:37-41. [PMID: 33887341 DOI: 10.1016/j.ijcard.2021.04.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 03/29/2021] [Accepted: 04/16/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Randomized evidence comparing newer-generation drug-eluting stents for multivessel percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) is limited. We sought to investigate clinical outcomes in STEMI patients undergoing multivessel PCI with thin-strut biodegradable polymer sirolimus-eluting stents (BP-SES) versus durable polymer everolimus-eluting stents (DP-EES). METHODS We performed a subgroup analysis of the BIOSTEMI (NCT02579031) randomized trial, which included individual patient data from STEMI patients enrolled into the BIOSCIENCE (NCT02579031) study. STEMI patients randomly allocated to BP-SES or DP-EES were divided into those undergoing multivessel versus culprit lesion-only PCI. The primary endpoint was target lesion failure (TLF), a composite of cardiac death, target vessel myocardial re-infarction or clinically indicated target lesion revascularization (TLR), within 24 months. RESULTS Among 1707 STEMI patients, 145 patients underwent multivessel PCI. At 2 years, TLF occurred in 2 patients (2.8%) treated with BP-SES and 13 patients (18.7%) treated with DP-EES (hazard ratio [HR], 0.14; 95% confidence interval (CI), 0.03-0.61; p = 0.009) in the multivessel PCI group, and in 40 (5.3%) and 61 (8.2%) patients treated with BP-SES and DP-EES respectively (HR, 0.64; 95%CI, 0.43-0.96; p = 0.03; p for interaction = 0.050) in the culprit lesion-only PCI group. In the multivessel PCI group, the rates of clinically indicated TLR (0% vs. 12.4%) and target vessel myocardial re-infarction (0% vs. 4.6%) at 2 years were lower in patients treated with BP-SES compared with DP-EES. CONCLUSION In a subgroup analysis of the BIOSTEMI trial, BP-SES were associated with lower 2-year TLF rates compared to DP-EES in STEMI patients undergoing multivessel PCI.
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Affiliation(s)
- Juan F Iglesias
- Division of Cardiology, Geneva University Hospitals, Geneva, Switzerland.
| | - Olivier Muller
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Marco Roffi
- Division of Cardiology, Geneva University Hospitals, Geneva, Switzerland
| | - David J Kurz
- Department of Cardiology, Triemlispital, Zurich, Switzerland
| | | | - Christoph Kaiser
- Department of Cardiology, Basel University Hospital, Basel, Switzerland
| | - Dik Heg
- CTU Bern, University of Bern, Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
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26
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Management of Culprit and Non-Culprit Lesions in Acute Coronary Syndrome. JOURNAL OF INTERDISCIPLINARY MEDICINE 2021. [DOI: 10.2478/jim-2021-0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Abstract
Multivessel coronary artery disease, defined by the presence of a significant stenosis (≥50% diameter) in two or more epicardial coronary vessels, usually occurs in more than 50% of patients with ST-segment elevation myocardial infarction. The latest guidelines indicate revascularization of the non-culprit artery with a recommendation of class IIB. However, the management of non-culprit lesions in patients with acute coronary syndrome is still a matter of debate. This article presents the most recent concepts related to the management of culprit and non-culprit coronary lesions, based on advanced imaging approaches, in order to identify high-risk patients and prevent further acute coronary syndromes.
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27
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Omer MA, Exaire JE, Jentzer JC, Sandoval YB, Singh M, Cagin CR, Elgendy IY, Tak T. Management of ST-Elevation Myocardial Infarction in High-Risk Settings. Int J Angiol 2021; 30:53-66. [PMID: 34025096 PMCID: PMC8128492 DOI: 10.1055/s-0041-1723941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Despite the widespread adoption of primary percutaneous intervention and modern antithrombotic therapy, ST-segment elevation myocardial infarction (STEMI) remains the leading cause of death in the United States and remains one of the most important causes of morbidity and mortality worldwide. Certain high-risk patients present a challenge for diagnosis and treatment. The widespread adoption of primary percutaneous intervention in addition to modern antithrombotic therapy has resulted in substantial improvement in the short- and long-term prognosis following STEMI. In this review, we aim to provide a brief analysis of the state-of-the-art treatment for patients presenting with STEMI, focusing on cardiogenic shock, current treatment and controversies, cardiac arrest, and diagnosis and treatment of mechanical complications, as well as multivessel and left main-related STEMI.
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Affiliation(s)
- Mohamed A. Omer
- Cardiovascular Services, Mayo Clinic Health System, La Crosse, Wisconsin
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jose E. Exaire
- Cardiovascular Services, Mayo Clinic Health System, La Crosse, Wisconsin
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Charles R. Cagin
- Cardiovascular Services, Mayo Clinic Health System, La Crosse, Wisconsin
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Islam Y. Elgendy
- Division of Cardiology, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Tahir Tak
- Cardiovascular Services, Mayo Clinic Health System, La Crosse, Wisconsin
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Complete Revascularization in Patients With STEMI and Multivessel Coronary Artery Disease: Is It Beneficial? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-020-00887-x] [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: 10/22/2022]
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Tiemuerniyazi X, Yan H, Song Y, Nan Y, Xu F, Feng W. Mid-term outcomes of coronary endarterectomy combined with coronary artery bypass grafting. Interact Cardiovasc Thorac Surg 2021; 32:188-195. [PMID: 33221913 PMCID: PMC8906773 DOI: 10.1093/icvts/ivaa252] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/23/2020] [Accepted: 09/16/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the mid-term outcome of coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG) and explore the potential risk factors for adverse events. METHODS A total of 208 consecutive patients underwent CE between 2008 and 2018 in our centre, of which 198 were included in this retrospective cohort study. The primary end point was major adverse cardiovascular and cerebrovascular events (MACCEs). Kaplan-Meier analysis was performed to evaluate event-free survival, whereas subgroup analysis and Cox regression were used to explore risk factors for the outcomes. RESULTS The median follow-up time was 34.7 months. CE + CABG was performed mainly on the left anterior descending artery (42.3%) or right coronary artery (42.3%). Both operative mortality and incidence of perioperative myocardial infarction were 1.5%. The overall survival at 3 and 5 years was 98.0% and 95.9%, whereas the MACCE-free survival was 93.7% and 89.4%, respectively. No significant difference in the incidence of MACCE was observed between on-pump and off-pump CE (P = 0.256) or between left anterior descending artery and non-left anterior descending artery endarterectomy (P = 0.540). Advanced age (>65 years) was associated with a higher risk of MACCE both in univariate [hazard ratio (HR) 3.62, 95% confidence interval (CI) 1.37-9.62; P = 0.010] and multivariate analysis (HR 3.59, 95% CI 1.32-9.77; P = 0.013). CONCLUSIONS When performed by experienced surgeons, CE + CABG could be an acceptable approach to achieve complete revascularization of diffusely diseased coronary arteries with satisfactory outcomes, although advanced age might increase the risk of MACCE.
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Affiliation(s)
- Xieraili Tiemuerniyazi
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hua Yan
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yangwu Song
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yifeng Nan
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fei Xu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Feng
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Corresponding author. Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beilishi Road No. 167, Xicheng District, 100037 Beijing, China. Tel: +86-10-88396771; fax: +86-10-88322355; e-mail: (W. Feng)
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Kuveljic J, Djuric T, Stankovic G, Dekleva M, Stankovic A, Alavantic D, Zivkovic M. Association of PHACTR1 intronic variants with the first myocardial infarction and their effect on PHACTR1 mRNA expression in PBMCs. Gene 2021; 775:145428. [PMID: 33460763 DOI: 10.1016/j.gene.2021.145428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/02/2020] [Accepted: 01/05/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Myocardial infarction (MI) and underlining atherosclerosis are the main causes of death worldwide. Phosphatase and actin regulator 1 (PHACTR1) variants have been associated with early onset MI, coronary artery disease and carotid dissection. PHACTR1 mRNA expression has been detected in tissues and cells related to atherosclerosis. Nonetheless, the true effect of PHACTR1 on vascular diseases is still unknown. Our aim was to examine the association of PHACTR1 intronic variants, rs9349379, rs2026458 and rs2876300, with MI and multi-vessel disease (MVD) and to assess their effect on PHACTR1 and EDN1 mRNA expression in PBMCs of patients six months after MI. METHODS The study enrolled 537 patients with the first MI and 310 controls. Gene expression was assessed in 74 patients six months after MI and 37 healthy controls. Rs9349379, rs2026458, rs2876300 and relative mRNA expressions were detected by TaqMan® technology. RESULTS The significant association between PHACTR1 variants and MI was not found, either individually or in haplotype. A higher frequency of rs2876300G-allele in MVD was rendered not significant after Bonferroni correction. PHACTR1 mRNA was significantly increased in PBMCs of patients six months after MI compared to controls (p = 0.02). Patients that carry ACG haplotype have increased PHACTR1 mRNA expression in PBMCs (p = 0.04). There was no effect of PHACTR1 variants on EDN1 mRNA expression. CONCLUSION Our findings suggest that PHACTR1 intronic variants may have a role in severity and progression of coronary atherosclerosis. Future research is needed to clarify the mechanism underlying the role of PHACTR1 in coronary atherosclerosis and MI.
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Affiliation(s)
- Jovana Kuveljic
- Laboratory for Radiobiology and Molecular Genetics, "Vinca" Institute of Nuclear Sciences, National Institute of the Republic of Serbia, University of Belgrade, Belgrade, Serbia.
| | - Tamara Djuric
- Laboratory for Radiobiology and Molecular Genetics, "Vinca" Institute of Nuclear Sciences, National Institute of the Republic of Serbia, University of Belgrade, Belgrade, Serbia.
| | - Goran Stankovic
- Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Milica Dekleva
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Department of Cardiology, University Clinical Center "Zvezdara", Belgrade, Serbia
| | - Aleksandra Stankovic
- Laboratory for Radiobiology and Molecular Genetics, "Vinca" Institute of Nuclear Sciences, National Institute of the Republic of Serbia, University of Belgrade, Belgrade, Serbia.
| | - Dragan Alavantic
- Laboratory for Radiobiology and Molecular Genetics, "Vinca" Institute of Nuclear Sciences, National Institute of the Republic of Serbia, University of Belgrade, Belgrade, Serbia.
| | - Maja Zivkovic
- Laboratory for Radiobiology and Molecular Genetics, "Vinca" Institute of Nuclear Sciences, National Institute of the Republic of Serbia, University of Belgrade, Belgrade, Serbia.
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Pilarczyk K, Werdan K, Russ M, Thiele H, Michels G, Boeken U, Thielmann M. The German-Austrian S3 Guideline "Cardiogenic Shock Due to Myocardial Infarction: Diagnosis, Monitoring, and Treatment". Thorac Cardiovasc Surg 2020; 69:684-692. [PMID: 33368106 DOI: 10.1055/s-0040-1719155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Despite advances in the treatment of acute myocardial infarction with subsequent mortality reduction, which are mainly caused by the early timing of revascularization, cardiogenic shock still remains the leading cause of death with mortality rates still approaching 40 to 50%. Cardiogenic shock is characterized by a multiorgan dysfunction syndrome, often complicated by a systemic inflammatory response syndrome that affects the outcome more than the reduction of the cardiac contractile function. However, both European and American guidelines on myocardial infarction focus on interventional or surgical aspects only. Therefore, experts from eight German and Austrian specialty societies including the German Society for Thoracic and Cardiovascular Surgery published the German-Austrian S3 guideline "cardiogenic shock due to myocardial infarction: diagnosis, monitoring, and treatment" to provide evidence-based recommendations for the diagnosis and treatment of infarction-related cardiogenic shock in 2010 covering the topics of early revascularization, revascularization techniques, intensive care unit treatment including ventilation, transfusion regimens, adjunctive medical therapy, and mechanical support devices. Within the last 3 years, this guideline was updated as some major recommendations were outdated, or new evidence had been found. This review will therefore outline the management of patients with cardiogenic shock complicating acute myocardial infarction according to the updated guideline with a major focus on evidence-based recommendations which have been found relevant for cardiac surgery.
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Affiliation(s)
- Kevin Pilarczyk
- Imland Hospital Rendsburg, Department for Intensice Care Medicine, Rendsburg, Schleswig-Holstein, Germany
| | - Karl Werdan
- Department of Internal Medicine III, Heart Center, Martin-Luther-University Halle-Wittenberg, University Hospital, Germany
| | - Martin Russ
- Department of Cardiology, Traunstein Hospital, Traunstein, Germany
| | - Holger Thiele
- University of Leipzig-Heart Center, Department of Internal Medicine/Cardiology, Leipzig, Germany
| | - Guido Michels
- Department of Acute and Emergency Care, St.-Antonius-Hospital gGmbH, Eschweiler, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, University Hospital, Moorenstrasse 5, Duesseldorf, Germany
| | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
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Ilardi F, Ferrone M, Avvedimento M, Servillo G, Gargiulo G. Complete Revascularization in Acute and Chronic Coronary Syndrome. Cardiol Clin 2020; 38:491-505. [PMID: 33036712 DOI: 10.1016/j.ccl.2020.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
In patients with multivessel disease, complete revascularization (CR) is the most biologically plausible approach irrespective of definition or type or clinical setting (acute or chronic coronary syndrome [ACS or CCS]). It aims at minimizing residual ischemia, relieving symptoms and reducing the risk of future cardiovascular events. Large evidence supports CR benefits in ACS, predominantly ST-segment elevation myocardial infarction, except cardiogenic shock, although optimal assessment and timing remain debated. In patients with CCS, when revascularization is indicated, a functional CR should be attempted. Therefore, heart-team is crucial in selecting the ideal strategy for each patient to optimize decision-making.
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Affiliation(s)
- Federica Ilardi
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini 5, Naples 80131, Italy; Mediterranea Cardiocentro, Via Orazio 2, Naples 80122, Italy
| | - Marco Ferrone
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini 5, Naples 80131, Italy; Division of Invasive Cardiology, Clinica Montevergine, Via Mario Malzoni, 5, Mercogliano (Avellino) 83013, Italy
| | - Marisa Avvedimento
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini 5, Naples 80131, Italy
| | - Giuseppe Servillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University of Naples, Via S. Pansini 5, Naples 80131, Italy
| | - Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini 5, Naples 80131, Italy.
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Yang Y, Cao Y, Jiang W. Our Perspective on Recovery of Left Ventricular Systolic Function in Young Adults With Myocardial Infarction. J Am Coll Cardiol 2020; 76:1606-1607. [DOI: 10.1016/j.jacc.2020.06.086] [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: 06/11/2020] [Accepted: 06/15/2020] [Indexed: 10/23/2022]
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Bossard M, Mehta SR. Complete or Incomplete Revascularization for ST-Segment Elevation Myocardial Infarction: The PRAMI Trial to COMPLETE. Interv Cardiol Clin 2020; 9:433-440. [PMID: 32921367 DOI: 10.1016/j.iccl.2020.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Many patients presenting with ST-segment elevation myocardial infarction (STEMI) have multivessel coronary artery disease (CAD). Following successful primary percutaneous coronary intervention (PCI) of culprit lesion, whether to routinely revascularize nonculprit lesions or treat them medically has been debated. Recently, the large-scale, multinational COMPLETE trial definitively established benefit of routine, staged, angiographically guided nonculprit lesion PCI in reducing hard clinical outcomes, including the composite of death from cardiovascular causes or new myocardial infarction, with no major safety concerns. A strategy of complete revascularization with routine nonculprit lesion PCI in suitable lesions should be standard of care in STEMI with multivessel CAD.
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Affiliation(s)
- Matthias Bossard
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Spitalstrasse 16, Luzern 6000, Switzerland
| | - Shamir R Mehta
- Population Health Research Institute, McMaster University, Hamilton General Hospital, Hamilton Health Sciences, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada.
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Bajraktari G, Bytyçi I, Henein MY, Alfonso F, Ahmed A, Jashari H, Bhatt DL. Complete revascularization for patients with multivessel coronary artery disease and ST-segment elevation myocardial infarction after the COMPLETE trial: A meta-analysis of randomized controlled trials. INTERNATIONAL JOURNAL OF CARDIOLOGY. HEART & VASCULATURE 2020; 29:100549. [PMID: 32577495 PMCID: PMC7301199 DOI: 10.1016/j.ijcha.2020.100549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/07/2020] [Accepted: 05/26/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The recently published COMPLETE trial has demonstrated that patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD), who underwent successful percutaneous coronary intervention (PCI) of both culprit and non-culprit (vs. culprit-only) lesions had a reduced risk of major adverse cardiac events (MACE), but not of cardiovascular or total mortality. The aim of this meta-analysis was to assess the efficacy of complete revascularization on cardiovascular or total mortality reduction using available randomized controlled trials (RCTs) including the COMPLETE trial, in hemodynamically stable STEMI patients with MVD. METHODS PubMed, MEDLINE, Embase, Scopus, Google Scholar, CENTRAL and ClinicalTrials.gov databases search identified 10 RCTs of 7033 patients with STEMI and MVD which compared complete (n = 3420) vs. only culprit lesion (n = 3613) PCI for a median 27.7 months follow-up. Random effect risk ratios were used to estimate for efficacy and safety outcomes. RESULTS Complete revascularization reduced the risk of MACE (10.4% vs.16.6%; RR = 0.59, 95% CI: 0.47 to 0.74, p < 0.0001), CV mortality (2.87% vs. 3.72%; RR = 0.73, 95% CI: 0.56 to 0.95, p = 0.02), reinfarction (5.1% vs. 7.1%; RR = 0.67, 95% CI: 0.52 to 0.86, p = 0.002), urgent revascularization (7.92% vs.17.4%; RR = 0.47, 95% CI: 0.30 to 0.73, p < 0.001), and CV hospitalization (8.68% vs.11.4%; RR = 0.65, 95% CI: 0.44to 0.96, p = 0.03) compared with culprit only revascularization. All-cause mortality, stroke, major bleeding events, or contrast induced nephropathy were not affected by the revascularization strategy. CONCLUSION The findings of this meta-analysis suggest that in patients with STEMI and MVD, complete revascularization is superior to culprit-only PCI in reducing the risk of MACE outcomes, including cardiovascular mortality, without increasing the risk of adverse safety outcomes.
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Affiliation(s)
- Gani Bajraktari
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- Clinic of Cardiology, University Clinical Centre of Kosovo, Prishtina, Kosovo
- University of Prishtina, Prishtina, Kosovo
| | - Ibadete Bytyçi
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- Clinic of Cardiology, University Clinical Centre of Kosovo, Prishtina, Kosovo
| | - Michael Y Henein
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Fernando Alfonso
- Cardiac Department, La Princesa University Hospital, Institute of Health Research, IIS-IP, CIBER-CV University Autónoma of Madrid, Madrid, Spain
| | - Ali Ahmed
- Veterans Affairs Medical Center, George Washington University, and Georgetown University, Washington, DC, USA
| | - Haki Jashari
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
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Elgendy IY, Mahtta D, Paniagua D. Multivessel PCI for Acute Myocardial Infarction: Where Do We Stand After The COMPLETE Trial? Curr Cardiol Rep 2020; 22:97. [PMID: 32710365 DOI: 10.1007/s11886-020-01340-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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 Multivessel coronary artery disease is frequently encountered in patients undergoing primary percutaneous coronary intervention (PCI). Several moderate-sized randomized trials have suggested that complete revascularization of non-culprit stenoses in ST-elevation myocardial infarction (STEMI) patients without cardiogenic shock is associated with improved outcomes driven solely by a reduction in the risk of future revascularization. RECENT FINDINGS The Complete versus Culprit-only Revascularization to Treat Multi-vessel disease after Early PCI for STEMI (COMPLETE) trial recently showed that a complete revascularization strategy for non-culprit stenoses for STEMI patients without cardiogenic shock, performed either during the index hospitalization or after discharge, reduces the risk of cardiac mortality or myocardial infarction (MI) driven by a reduction in the risk of MI at a median of 3 years. In STEMI patients without cardiogenic shock undergoing primary PCI, a complete revascularization strategy for non-culprit stenoses, performed either during the index hospitalization or shortly after discharge, improves outcomes and should be considered as the default strategy whenever feasible.
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Affiliation(s)
- Islam Y Elgendy
- Division of Cardiology, Weill Cornell Medicine-Qatar, Doha, Qatar.
| | - Dhruv Mahtta
- Division of Cardiovascular Medicine, Baylor College of Medicine, Houston, TX, USA
| | - David Paniagua
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Gershlick AH, Banning AS. Complete revascularisation in the STEMI patient: is it worth the effort? EUROINTERVENTION 2020; 16:195-199. [PMID: 32597764 DOI: 10.4244/eijv16i3a34] [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: 11/23/2022]
Affiliation(s)
- Anthony H Gershlick
- University of Leicester, University Hospitals of Leicester, NIHR Leicester Biomedical Research Centre, Leicester, United Kingdom
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Ahmad Y, Howard JP, Arnold A, Prasad M, Seligman H, Cook CM, Warisawa T, Shun‐Shun M, Ali Z, Parikh MA, Al‐Lamee R, Sen S, Francis D, Moses JW, Leon MB, Stone GW, Karmpaliotis D. Complete Revascularization by Percutaneous Coronary Intervention for Patients With ST-Segment-Elevation Myocardial Infarction and Multivessel Coronary Artery Disease: An Updated Meta-Analysis of Randomized Trials. J Am Heart Assoc 2020; 9:e015263. [PMID: 32476540 PMCID: PMC7429036 DOI: 10.1161/jaha.119.015263] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 05/04/2020] [Indexed: 01/10/2023]
Abstract
Background For patients with ST-segment-elevation myocardial infarction (STEMI) and multivessel coronary artery disease, the optimal treatment of the non-infarct-related artery has been controversial. This up-to-date meta-analysis focusing on individual clinical end points was performed to further evaluate the benefit of complete revascularization with percutaneous coronary intervention for patients with STEMI and multivessel coronary artery disease. Methods and Results We systematically identified all randomized trials comparing complete revascularization with percutaneous coronary intervention to culprit-only revascularization for multivessel disease in STEMI and performed a random-effects meta-analysis. The primary efficacy end point was cardiovascular death analyzed on an intention-to-treat basis. Secondary end points included all-cause mortality, myocardial infarction, and unplanned revascularization. Ten studies (7542 patients) were included: 3664 patients were randomized to complete revascularization and 3878 to culprit-only revascularization. Across all patients, complete revascularization was superior to culprit-only revascularization for reduction in the risk of cardiovascular death (relative risk [RR], 0.68; 95% CI, 0.47-0.98; P=0.037; I2=21.8%) and reduction in the risk of myocardial infarction (RR, 0.65; 95% CI, 0.54-0.79; P<0.0001; I2=0.0%). Complete revascularization also significantly reduced the risk of unplanned revascularization (RR, 0.37; 95% CI, 0.28-0.51; P<0.0001; I2=64.7%). The difference in all-cause mortality with percutaneous coronary intervention was not statistically significant (RR, 0.85; 95% CI, 0.69-1.04; P=0.108; I2=0.0%). Conclusions For patients with STEMI and multivessel disease, complete revascularization with percutaneous coronary intervention significantly improves hard clinical outcomes including cardiovascular death and myocardial infarction. These data have implications for clinical practice guidelines regarding recommendations for complete revascularization following STEMI.
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Affiliation(s)
- Yousif Ahmad
- Columbia University Medical Center/New York‐Presbyterian HospitalNew YorkNY
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - James P. Howard
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Ahran Arnold
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Megha Prasad
- Columbia University Medical Center/New York‐Presbyterian HospitalNew YorkNY
| | - Henry Seligman
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Christopher M. Cook
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Takayuki Warisawa
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Matthew Shun‐Shun
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Ziad Ali
- Columbia University Medical Center/New York‐Presbyterian HospitalNew YorkNY
| | - Manish A. Parikh
- Columbia University Medical Center/New York‐Presbyterian HospitalNew YorkNY
| | - Rasha Al‐Lamee
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Sayan Sen
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Darrel Francis
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Jeffrey W. Moses
- Columbia University Medical Center/New York‐Presbyterian HospitalNew YorkNY
| | - Martin B. Leon
- Columbia University Medical Center/New York‐Presbyterian HospitalNew YorkNY
| | - Gregg W. Stone
- Cardiovascular Research FoundationNew YorkNY
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
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Sanz-Sánchez J, Chiarito M, Regazzoli D, Cannata F, Condorelli G, Reimers B, Stefanini GG. Impact of complete revascularization on mortality in patients with ST-segment elevation myocardial infarction and multivessel disease: an updated meta-analysis. J Cardiovasc Med (Hagerstown) 2020; 21:988-990. [DOI: 10.2459/jcm.0000000000000979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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40
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Cayla G, Lattuca B. Long-Term Outcomes on Multivessel Disease STEMI Patients. J Am Coll Cardiol 2019; 74:3095-3098. [DOI: 10.1016/j.jacc.2019.10.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 10/27/2019] [Accepted: 10/28/2019] [Indexed: 11/30/2022]
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