A More COMPLETE Picture of Revascularization in STEMI

The optimal timing for intervention in patients with ST-segment elevation myocardial infarction and multivessel disease: a systematic review and meta-analysis

Purpose

The optimal timing for nonculprit vascular reconstruction surgery in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary disease (MVD) is still controversial. Our aim was to explore the optimal intervention time for percutaneous coronary intervention (PCI) in STEMI patients who underwent MVD.

Methods

The PubMed/Medline, EMBASE, Cochrane Library, and ClinicalTrials.gov databases were searched from inception to January 1, 2024 for clinical studies comparing immediate multivessel PCI and staged multivessel PCI in patients with STEMI. The primary outcomes were death from any cause, cardiovascular death, noncardiac death, myocardial infarction (MI) and unplanned ischemia-driven revascularization. The secondary outcomes were ischemic stroke, stent thrombosis, renal dysfunction and major bleeding. The risk ratios (RRs) and odds ratios (ORs) were calculated with fixed-effects models and random-effects models, and 95% confidence intervals (CIs) were calculated.

Findings

Five randomized trials with 2,782 patients and six prospective observational studies with 3,131 patients were selected for inclusion in this meta-analysis. The staged PCI group had significantly lower pooled RRs for myocardial infarction (0.43, 95% CI = 0.27-0.67; P = 0.0002) and unplanned ischemia-driven revascularization (0.57, 95% CI = 0.41-0.78; P = 0.0004). There were no significant differences in any cause of death, cardiovascular cause of death, or noncardiac cause of death. However, the results of prospective observational studies in the real world indicated that the staged PCI group had significantly lower pooled ORs for all-cause mortality (2.30, 95% CI = 1.22-4.34; P = 0.01), cardiovascular death (2.29, 95% CI = 1.10-4.77; P = 0.03), and noncardiovascular death (3.46, 95% CI = 1.40-8.56; P = 0.007).

Implications

According to our randomized trial analysis, staged multivessel PCI significantly reduces the risk of myocardial infarction and unplanned ischemia-driven revascularization compared to immediate multivessel PCI. There was no significant difference between the two groups in terms of all-cause mortality, cardiovascular mortality, or noncardiovascular mortality risk. However, prospective non-randomized studies suggest there might be a benefit in mortality in the staged PCI group. Therefore, staged multivessel PCI may be the optimal PCI strategy for STEMI patients with MVD.

Systematic review and meta-analysis comparing complete versus incomplete or culprit-only revascularization by percutaneous coronary intervention in elderly patients with acute coronary syndrome

BACKGROUND

Complete revascularization (CR) is favored over culprit-only or incomplete revascularization (IR) for patients with acute coronary syndrome (ACS) and multi-vessel disease (MVD) due to better long-term outcomes. However, the optimal revascularization strategy is currently uncertain in elderly patients, where frailty, polypharmacy, multi-morbidity, inherent bleeding risk and presumed cognitive decline can often burden the decision-making process.

METHODS

We searched Medline, PubMed, and Google Scholar from inception to April 2024. The search of databases identified relevant studies that reported the comparative effects of CR and IR in the elderly population undergoing percutaneous coronary intervention (PCI). Data was pooled for individual studies using random-effects models on Comprehensive Meta-Analysis software, with statistical significance set at p < 0.05.

RESULTS

The meta-analysis included 14 studies and 62577 patients. CR demonstrated a significant reduction in all-cause mortality [RR: 0.680; 95 % CI: 0.57-0.82; p=<0.001], cardiovascular-related mortality [RR: 0.620; 95 % CI: 0.478-0.805; p=<0.001], and myocardial infarction [RR: 0.675; 95 % CI: 0.553-0.823; p=<0.001] rates. There was no difference between the risk of stroke [RR: 1.044; 95 % CI: 0.733-1.486; p = 0.81], major bleeding [RR: 1.001; 95 % CI: 0.787-1.274; p = 0.991], stent thrombosis [RR: 1.015; 95 % CI: 0.538-1.916; p = 0.936], and contrast-induced acute kidney injury [RR: 1.187; 95 % CI: 0.963-1.464; p = 0.109].

CONCLUSION

The meta-analysis suggests that CR may be a favorable revascularization strategy for elderly patients undergoing PCI, displaying a significant decrease in mortality and repeat myocardial infarction risk.

Complete revascularization in elderly patients with myocardial infarction-a safe, effective, and necessary strategy?

The FIRE trial compared culprit-only revascularization to physiology-guided complete revascularization strategy in elderly patients presenting with myocardial infarction. The study has shown that it is a safe approach and may confer additional prognostic benefit in patients with NSTEMI.

Timing of Complete Revascularization with Multivessel PCI for Myocardial Infarction

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Complete or Culprit-Only PCI in Older Patients with Myocardial Infarction

BACKGROUND

The benefit of complete revascularization in older patients (≥75 years of age) with myocardial infarction and multivessel disease remains unclear.

METHODS

In this multicenter, randomized trial, we assigned older patients with myocardial infarction and multivessel disease who were undergoing percutaneous coronary intervention (PCI) of the culprit lesion to receive either physiology-guided complete revascularization of nonculprit lesions or to receive no further revascularization. Functionally significant nonculprit lesions were identified either by pressure wire or angiography. The primary outcome was a composite of death, myocardial infarction, stroke, or any revascularization at 1 year. The key secondary outcome was a composite of cardiovascular death or myocardial infarction. Safety was assessed as a composite of contrast-associated acute kidney injury, stroke, or bleeding.

RESULTS

A total of 1445 patients underwent randomization (720 to receive complete revascularization and 725 to receive culprit-only revascularization). The median age of the patients was 80 years (interquartile range, 77 to 84); 528 patients (36.5%) were women, and 509 (35.2%) were admitted for ST-segment elevation myocardial infarction. A primary-outcome event occurred in 113 patients (15.7%) in the complete-revascularization group and in 152 patients (21.0%) in the culprit-only group (hazard ratio, 0.73; 95% confidence interval [CI], 0.57 to 0.93; P = 0.01). Cardiovascular death or myocardial infarction occurred in 64 patients (8.9%) in the complete-revascularization group and in 98 patients (13.5%) in the culprit-only group (hazard ratio, 0.64; 95% CI, 0.47 to 0.88). The safety outcome did not appear to differ between the groups (22.5% vs. 20.4%; P = 0.37).

CONCLUSIONS

Among patients who were 75 years of age or older with myocardial infarction and multivessel disease, those who underwent physiology-guided complete revascularization had a lower risk of a composite of death, myocardial infarction, stroke, or ischemia-driven revascularization at 1 year than those who received culprit-lesion-only PCI. (Funded by Consorzio Futuro in Ricerca and others; FIRE ClinicalTrials.gov number, NCT03772743.).

Complete revascularization of multivessel coronary artery disease in patients with ST elevation acute coronary syndrome - for whom and when? A comprehensive review

Atherosclerosis is the most common cause of coronary steno-occlusive disease and acute myocardial infarction is the leading cause of death in industrialized countries. In patients with acute ST elevation myocardial infarction (STEMI), there is unquestionable evidence that primary percutaneous coronary intervention providing recanalization of the infarct related artery (IRA) is the preferred reperfusion strategy. Nevertheless, up to 50% of patients with STEMI have multivessel coronary artery disease defined as at least 50% stenosis exclusive of IRA. There is conflicting data regarding the optimal treatment strategy and timing in such patients. Currently, it is assumed that stable patients might benefit from complete revascularization particularly in reducing the need for future unplanned procedures but only culprit lesion should be treated during index procedure in unstable patients. In this article, we provide a comprehensive overview of this important and currently highly debated topic.

Current recommendations for revascularization of non-infarct-related artery in patients presenting with ST-segment elevation myocardial infarction and multivessel disease

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.

Economic evaluation of complete revascularization versus stress echocardiography-guided revascularization in the STEACS with multivessel disease

INTRODUCTION AND OBJECTIVES

Economic studies may help decision making in the management of multivessel disease in the setting of myocardial infarction. We sought to perform an economic evaluation of CROSS-AMI (Complete Revascularization or Stress Echocardiography in Patients With Multivessel Disease and ST-Segment Elevation Acute Myocardial Infarction) randomized clinical trial.

METHODS

We performed a cost minimization analysis for the strategies (complete angiographic revascularization [ComR] and selective stress echocardiography-guided revascularization [SelR]) compared in the CROSS-AMI clinical trial (N=306), attributable the initial hospitalization and readmissions during the first year of follow-up, using current rates for health services provided by our health system.

RESULTS

The index hospitalization costs were higher in the ComR group than in SelR arm (19 657.9±6236.8 € vs 14 038.7±4958.5 €; P <.001). There were no differences in the costs of the first year of follow-up rehospitalizations between both groups for (ComR 2423.5±4568.0 vs SelR 2653.9±5709.1; P=.697). Total cost was 22 081.3±7505.6 for the ComR arm and 16 692.6±7669.9 for the SelR group (P <.001).

CONCLUSIONS

In the CROSS-AMI trial, the initial extra economic costs of the ComR versus SelR were not offset by significant savings during follow-up. SelR seems to be more efficient than ComR in patients with ST-segment elevation acute coronary syndrome and multivessel disease treated by emergent angioplasty. Study registred at ClinicalTrial.gov (Identifier: NCT01179126).

Revascularization Practices and Outcomes in Patients With Multivessel Coronary Artery Disease Who Presented With Acute Myocardial Infarction and Cardiogenic Shock in the US, 2009-2018

Importance

Cardiogenic shock after acute myocardial infarction (AMI) is associated with high mortality, particularly among patients with multivessel coronary artery disease. Recent evidence suggests that use of multivessel percutaneous coronary intervention (PCI) may be associated with harm. However, little is known about recent patterns of care and outcomes for this patient population.

Objective

To evaluate patterns in the use of multivessel PCI vs culprit-vessel PCI in AMI and cardiogenic shock and outcomes in the US from 2009 to 2018.

Design, Setting, and Participants

This cohort study identified all patients in the CathPCI Registry) with AMI and cardiogenic shock who had multivessel coronary artery disease and underwent PCI between July 1, 2009, and March 31, 2018.

Exposures

Multivessel or culprit-vessel PCI for AMI and shock.

Primary Outcomes and Measures

The primary outcome was in-hospital mortality. Temporal trends and hospital variation in PCI strategies were evaluated, while accounting for differences in case mix using hierarchical models. As a secondary outcome, the association of PCI strategy with postdischarge outcomes was evaluated in the subset of patients who were Medicare beneficiaries.

Results

Of 64 301 patients (mean [SD] age, 66.4 [12.5] years; 20 366 [31.7%] female; 54 538 [84.8%] White) with AMI and shock at 1649 US hospitals, 34.9% had primary multivessel PCI. In the subgroup of 48 943 patients with ST-segment elevation myocardial infarction (STEMI), 31.5% underwent multivessel PCI. Between 2009 and 2018, this percentage increased by 6.7% per year for AMI and 5.8% for STEMI. Overall, multivessel PCI was associated with a greater adjusted risk of in-hospital complications (odds ratio [OR], 1.18; 95% CI, 1.14-1.23) and with greater in-hospital mortality in patients with STEMI (OR, 1.11; 95% CI, 1.06-1.16). Among Medicare beneficiaries, multivessel PCI use was not associated with postdischarge 1-year mortality (51.5% vs 49.8%; risk-adjusted OR, 0.97; 95% CI, 0.90-1.04; P = .37). Significant hospital variation was found in the use of multivessel PCI, with a higher multivessel PCI rate for similar patients across hospitals (median OR, 1.37; 95% CI, 1.33-1.41). Patients at hospitals with high rates of PCI in STEMI use had higher risk-adjusted in-hospital mortality (highest vs lowest hospital multivessel PCI quartile: OR, 1.10; 95% CI, 1.02-1.19).

Conclusions and Relevance

This cohort study found that multivessel PCI was increasingly used as the revascularization strategy in AMI and shock and that hospitals that used multivessel PCI more, especially among patients with STEMI, had worse outcomes. With recent evidence suggesting harm with this strategy, there appears to be an urgent need to change practice and improve outcomes in this high-risk population.

ST-segment elevation myocardial infarction: Historical perspective and new horizons

After a brief history of the emergence of modern therapy for acute ST-elevation myocardial infarction, we discuss the issues that dominate ongoing studies and are the focus of intense debates. The role of angiography, pharmacotherapy, thrombus aspiration, management of multi-vessel disease, mechanical complications and cardiogenic shock and the quest for myocardial salvage are discussed.

Determining the Significance of Coronary Plaque Lesions: Physiological Stenosis Severity and Plaque Characteristics

The evaluation of coronary lesions has evolved in recent years. Physiologic-guided revascularization (particularly with pressure-derived fractional flow reserve (FFR)) has led to superior outcomes compared to traditional angiographic assessment. A greater importance, therefore, has been placed on the functional significance of an epicardial lesion. Despite the improvements in the limitations of angiography, insights into the relationship between hemodynamic significance and plaque morphology at the lesion level has shown that determining the implications of epicardial lesions is rather complex. Investigators have sought greater understanding by correlating ischemia quantified by FFR with plaque characteristics determined on invasive and non-invasive modalities. We review the background of the use of these diagnostic tools in coronary artery disease and discuss the implications of analyzing physiological stenosis severity and plaque characteristics concurrently.

Meta-Analysis Comparing Complete Versus Infarct-Related Artery Revascularization in Patients With ST-Elevation Myocardial Infarction and Multivessel Coronary Disease

A strategy of complete revascularization (CR) versus infarct-related artery revascularization (IRA) in patients with ST-elevation myocardial infarction (STEMI) continues to be a subject of debate. We performed an updated meta-analysis to compare the 2 strategies. Outcomes of interest included major adverse cardiovascular events (MACE), cardiovascular mortality, all-cause mortality, stroke, repeat revascularization, myocardial infarction, and contrast-induced nephropathy. Ten randomized trials including 7,423 patients (CR = 3,574 and IRA = 3,849), with a follow-up of 2.0 ± 0.8 years were included. There was a significant reduction in MACE with CR versus IRA (10.7% vs 18.6%, relative risk [RR] 0.64, 95% confidence interval [CI] 0.51 to 0.81, p = 0.002, I² = 66%), with higher risk reduction with immediate versus stages revascularization (RR 0.40, 95% CI 0.32 to 0.5 vs RR 0.69, 95% CI 0.54 to 0.89, P-interaction = 0.002). Complete revascularization was associated with lower rates of repeat revascularization (4.0% vs 11.7%, RR 0.44, 95% CI 0.28 to 0.70, p <0.0001, I² = 81%), and a nonsignificant trend toward lower cardiovascular mortality (2.8% vs 3.7%, RR 0.78, 95% CI 0.60 to 1.03, p = 0.08, I² = 0%). However, there was no difference between the 2 strategies in all-cause mortality (4.6% vs 4.8%, RR 0.90, 95% CI 0.73 to 1.12, p = 0.36, I² = 0%), myocardial infarction (5.2% vs 6.5%, RR 0.73, 95% CI, 0.58 to 1.08, p = 0.08, I² = 30%), stroke (1.5% vs 1.2%, RR 1.14, 95% CI 0.56 to 2.29, p = 0.33, I² = 14%), or contrast-induced nephropathy (1.6% vs 1.2%, RR 1.35, 95% CI 0.85 to 2.15, p = 0.78, I² = 0%). In conclusion, CR in patients with STEMI is associated with significant reduction in MACE compared with IRA. This reduction is derived mainly by the low rates of repeat revascularization in the CR group.