Timing of Complete Revascularization with Multivessel PCI for Myocardial Infarction

Correlation between abnormal microvascular perfusion and quantitative flow ratio after primary PCI in patients with STEMI

AIMS

Timely assessment of abnormal microvascular perfusion (MVP) may improve prognosis in patients with ST-segment elevation myocardial infarction (STEMI). This study aimed to determine the clinical implications of contrast-flow quantitative flow ratio (cQFR) in evaluating abnormal MVP and subsequent outcomes among STEMI patients after successful primary percutaneous coronary intervention (PPCI).

METHODS

The study population consisted of 2 independent cohorts. The diagnostic cohort was used to evaluate the correlation and diagnostic accuracy of cQFR in predicting abnormal MVP. In this cohort, MVP and cQFR of the culprit vessel (n = 186) were assessed from a prospective consecutive registry. Abnormal MVP was determined using myocardial contrast perfusion echocardiography (MCE) in the culprit vessel after PPCI. The prognostic cohort consisted of STEMI patients undergoing PPCI who were followed for a minimum of 2 years (n = 1931). The primary outcome was all-cause mortality.

RESULTS

In the diagnostic cohort, cQFR exhibited a moderate correlation with abnormal MVP assessed by MCE. Specificity, sensitivity, and area under the curve of post-PPCI cQFR to predict abnormal MVP were 81.6 %, 50.9 % and 0.709 (95 % confidence interval: 0.635-0.783), respectively, with the best cut-off value of 0.875. In the prognostic cohort, patients with cQFR <0.875 showed a significantly higher risk of long-term mortality compared to those with cQFR ≥0.875 (median follow-up: 52 months; mortality: 8.0 % vs. 3.8 %; p < 0.001). Cox-regression analysis revealed that cQFR < 0.875 was an independent predictor of long-term mortality (adjusted HR: 2.132; 95 % CI: 1.358-3.346; p = 0.001) after adjusting for age, gender, diabetes mellitus, hyperlipidemia, symptom to balloon time, culprit vessel.

CONCLUSIONS

We found that cQFR demonstrated a relatively good performance in predicting abnormal MVP in patients with STEMI after successful PPCI. A cQFR value below 0.875 is an independent predictor of both abnormal MVP and long-term mortality. (Prognostic implication of cQFR in STEMI patients; NCT04996901).

Association of Circulating Phenylacetylglutamine With Multi-Vessel Coronary Disease Severity and Outcomes in ST-Segment-Elevation Myocardial Infarction

BACKGROUND

There is a lack of evidence regarding the association between plasma phenylacetylglutamine levels and lesion severity and clinical prognosis in patients with ST-segment elevation myocardial infarction (STEMI) with multivessel coronary disease (MVCD). This study aims to investigate the potential of phenylacetylglutamine as a biomarker for major adverse cardiovascular events (MACEs) of patients with STEMI and MVCD.

METHODS AND RESULTS

Clinical data and blood samples were collected from 631 patients with STEMI and MVCD, who underwent primary percutaneous coronary intervention. Quantitative coronary angiography analysis was performed using the QAngio XA 7.3 system. Plasma phenylacetylglutamine concentrations were measured by rapid resolution liquid chromatography quadrupole time-of-flight mass spectrometry. Among a total of 631 patients, median plasma phenylacetylglutamine level was 3.8 (2.1-6.8) μmol/L and the cumulative MACE rate at follow-up was 12%. Plasma phenylacetylglutamine levels of patients with MACE were significantly higher than patients without MACE. We employed restricted cubic spline, Kaplan-Meier curves, and Cox proportional hazard models to explore the association between plasma phenylacetylglutamine and prognosis of patients with STEMI and MVCD. Per SD, an increment in phenylacetylglutamine was associated with a 24% higher risk of complexity lesion. Higher phenylacetylglutamine level was an independent predictor of MACEs (hazard ratio [HR], 2.76 [95% CI, 1.62-4.72]). A novel prognostic scoring system was established by combining phenylacetylglutamine levels with the synergy between percutaneous coronary intervention with Taxus and cardiac surgery score, with higher scores significantly increasing the risk of MACEs (HR, 4.01 [95% CI, 2.04-7.89]).

CONCLUSIONS

Phenylacetylglutamine levels were associated with lesion complexity and prognosis, may serve as a novel biomarker in patients with STEMI and MVCD.

Completeness, timing, and guidance of percutaneous coronary intervention for myocardial infarction and multivessel disease: a systematic review and network meta-analysis

BACKGROUND

Trials assessing the prognostic influence of the completeness, timing, and guidance of percutaneous coronary intervention (PCI) for haemodynamically stable acute myocardial infarction (MI) and multivessel coronary artery disease (MV-CAD) have provided heterogeneous results.

AIMS

We aimed to comprehensively and simultaneously assess the available evidence on the completeness, timing, and guidance of PCI for acute MI and MV-CAD.

METHODS

Major electronic databases were screened to identify randomised trials comparing at least two PCI strategies for acute MI and MV-CAD. Recurrent MI and cardiac death were the primary and co-primary outcomes. Frequentist and Bayesian 5- and 3-node network meta-analyses were conducted along with complementary analyses to explore potential sources of heterogeneity.

RESULTS

Fourteen trials, including 14,433 patients, were pooled. In the frequentist 5-node analysis, angiography-guided immediate complete revascularisation (CR) reduced MI compared with infarct-related artery (IRA)-only revascularisation (hazard ratio [HR] 0.42, 95% confidence interval [CI]: 0.27-0.66), angiography-guided staged CR (HR 0.56, 95% CI: 0.36-0.87), and functionally guided staged CR (HR 0.37, 95% CI: 0.20-0.69). Functionally guided immediate CR was associated with reduced MI compared with IRA-only revascularisation (HR 0.53, 95% CI 0.34-0.82). The Bayesian analysis confirmed only an advantage of angiography-guided immediate CR over IRA-only revascularisation. In frequentist 3-node analysis, immediate CR reduced MI (HR 0.51, 95% CI: 0.37-0.70) and cardiac death (HR 0.68, 95% CI: 0.50-0.93) compared with IRA-only revascularisation and MI compared with staged CR (HR 0.55, 95% CI: 0.38-0.79). The Bayesian analysis did not confirm the reduction in cardiac death. CR, regardless of the type of guidance and especially when immediate, reduced the rate of any revascularisation compared with IRA-only revascularisation.

CONCLUSIONS

In haemodynamically stable patients with acute MI and non-complex MV-CAD undergoing PCI, immediate CR following successful culprit lesion treatment reduces recurrent MI compared with IRA-only revascularisation and staged CR. Whether CR is associated with reduced cardiovascular death remains uncertain.

State of the Art of Primary PCI: Present and Future

Primary percutaneous coronary intervention (PCI) has revolutionized the management of ST-elevation myocardial infarction (STEMI), markedly improving patient outcomes. Despite technological advancements, pharmacological innovations, and refined interventional techniques, STEMI prognosis remains burdened by a persistent incidence of cardiac death and heart failure (HF), with mortality rates plateauing over the last decade. This review examines current practices in primary PCI, focusing on critical factors influencing patient outcomes. Moreover, it explores future developments, emphasizing the role of microvascular dysfunction-a critical but often under-recognized contributor to adverse outcomes, including incident HF and mortality, and has emerged as a key therapeutic frontier. Strategies aimed at preserving microvascular function, mitigating ischemia-reperfusion injury, and reducing infarct size are discussed as potential avenues for improving STEMI management. By addressing these challenges, the field can advance toward more personalized and effective interventions, potentially breaking the current deadlock in mortality rates and improving longer-term prognosis.

Optimal Strategy for Complete Revascularization in ST-Segment Elevation Myocardial Infarction and Multivessel Disease: A Network Meta-Analysis

BACKGROUND

In patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease, most but not all randomized trials have reported that complete revascularization (CR) offers advantages over culprit vessel-only revascularization. In addition, the optimal timing and assessment methods for CR remain undetermined.

OBJECTIVES

The purpose of this study was to identify the optimal revascularization strategy in patients with STEMI and multivessel disease, using a network meta-analysis of randomized controlled trials.

METHODS

We searched PUBMED and EMBASE for randomized trials evaluating revascularization strategies in patients with STEMI and multivessel disease through July 2024. A network meta-analysis was performed analyzing CR vs culprit vessel-only revascularization as well as the timing of CR (immediate CR vs staged CR). Outcomes were also assessed with 4 CR strategies based on whether revascularization was immediate or staged and whether it was angiographically guided or functionally guided. The primary outcome was major adverse cardiovascular events (MACE).

RESULTS

A total of 26 randomized trials that enrolled 15,902 patients were included. The mean weighted duration of follow-up was 25.2 ± 15.7 months. MACE was reduced with both immediate CR and staged CR compared with culprit-vessel-only treatment (RR: 0.48; 95% CI: 0.36-0.64 and RR: 0.65; 95% CI: 0.52-0.82, respectively), whether with angiographic or functional guidance. Immediate CR was associated with reduced MACE compared with staged CR (RR: 0.74; 95% CI: 0.56-0.97), whether CR was guided angiographically or functionally (RR: 0.77; 95% CI: 0.61-0.99 and RR: 0.49; 95% CI: 0.27-0.89, respectively) caused by reductions in MI. However, when the analysis was restricted to studies that reported both all MI and nonprocedural MI, the benefit of immediate CR in reducing MI compared with staged CR was diminished after excluding procedural MI (RR: 0.44; 95% CI: 0.27-0.71 with procedural MI vs RR: 0.65; 95% CI: 0.36-1.16 without procedural MI).

CONCLUSIONS

Among patients with STEMI and multivessel disease, outcomes were better with immediate or staged CR compared with culprit vessel-only treatment, whether with angiographic or functional guidance.

Comparison of Multivessel Versus Culprit-Vessel-Only Revascularization in Patients With STEMI and Multivessel Disease During Primary PCI: In-Hospital Outcomes From the CCC-ACS Project in China

BACKGROUND

The consensus on whether acute ST-segment elevation myocardial infarction (STEMI) patients with multivessel coronary artery disease (MVD) benefit from complete revascularization during primary percutaneous coronary intervention (PCI) is unclear.

AIMS

This study aims to assess the impact of multivessel PCI (MV-PCI) versus culprit-vessel-only PCI (CV-PCI) on in-hospital outcomes in a Chinese population.

METHODS

We evaluated STEMI patients with MVD undergoing PCI, registered in the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome (CCC-ACS) project, from November 2014 to December 2019. Using inverse probability of treatment weighting (IPTW) and multivariable Cox regression, we compared the incidence of in-hospital Major Adverse Cardiac Events (MACE) and other adverse clinical outcomes between the MV-PCI and CV-PCI groups.

RESULTS

Among 8138 patients included, 840 (10.3%) underwent MV-PCI, and 7298 (89.7%) underwent CV-PCI. MV-PCI was associated with higher in-hospital MACE (2.0% vs. 0.9%, p = 0.005), all-cause mortality (1.7% vs. 0.7%, p = 0.003), and contrast-induced acute kidney injury (CI-AKI) (13.6% vs. 10.2%, p = 0.002), after IPTW adjustment. The multivariable Cox analysis further validated the increased risks associated with MV-PCI.

CONCLUSION

In the Chinese STEMI population with MVD, participating in the CCC-ACS project, MV-PCI during primary PCI was linked to higher in-hospital adverse events compared to CV-PCI. These findings advocate for a cautious approach to MV-PCI in this setting, suggesting a potential preference for a staged PCI strategy for nonculprit vessels.

TRIAL REGISTRATION

The information of clinical trial registration for CCC-ACS project can be found at http://clinicaltrials.gov/study/NCT02306616.

Timing of multivessel revascularization in stable patients with STEMI: a systematic review and network meta-analysis

INTRODUCTION AND OBJECTIVES

Multivessel percutaneous coronary intervention (MV-PCI) is recommended in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD) without cardiogenic shock. The present network meta-analysis investigated the optimal timing of MV-PCI in this context.

METHODS

We pooled the aggregated data from randomized trials investigating stable STEMI patients with multivessel CAD treated with a strategy of either MV-PCI or culprit vessel-only PCI. The primary outcome was all-cause death. The main secondary outcomes were cardiovascular death, myocardial infarction, and unplanned ischemia-driven revascularization.

RESULTS

Among 11 trials, a total of 10 507 patients were randomly assigned to MV-PCI (same sitting, n=1683; staged during the index hospitalization, n=3460; staged during a subsequent hospitalization within 45 days, n=3275) or to culprit vessel-only PCI (n=2089). The median follow-up was 18.6 months. In comparison with culprit vessel-only PCI, MV-PCI staged during the index hospitalization significantly reduced all-cause death (risk ratio, 0.73; 95%CI, 0.56-0.92; P=.008) and ranked as possibly the best treatment option for this outcome compared with all other strategies. In comparison with culprit vessel-only PCI, a MV-PCI reduced cardiovascular mortality without differences dependent on the timing of revascularization. MV-PCI within the index hospitalization, either in a single procedure or staged, significantly reduced myocardial infarction and unplanned ischemia-driven revascularization, with no significant difference between each other.

CONCLUSIONS

In patients with STEMI and multivessel CAD without cardiogenic shock, multivessel PCI within the index hospitalization, either in a single procedure or staged, represents the safest and most efficacious approach. The different timings of multivessel PCI did not result in any significant differences in all-cause death. This study is registered at PROSPERO (CRD42023457794).

Complete versus culprit-only percutaneous coronary intervention in elderly patients with acute coronary syndrome and multivessel coronary artery disease: A systematic review and meta-analysis

BACKGROUND

Culprit-only percutaneous coronary intervention (PCI) is commonly performed for acute coronary syndrome (ACS) with multivessel coronary artery disease (MVD) in the elderly. Complete revascularization has been shown to benefit the general population, yet its safety and efficacy in older patients are uncertain.

METHODS

Following PRISMA guidelines, we systematically searched PubMed, Embase, and Cochrane databases for randomized controlled trials (RCTs) comparing complete versus culprit-only PCI in patients ≥65 years old with ACS and MVD. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes included myocardial infarction (MI), ischemia-driven revascularization (IDR), all-cause mortality, and cardiovascular mortality. Data were pooled using a random effects model with a restricted maximum likelihood estimator to generate risk ratios (RRs).

RESULTS

Five RCTs with 4105 patients aged ≥65 years were included. Compared with culprit-only PCI, complete revascularization reduced MI (RR 0.65; 95 % CI 0.49-0.85; p < 0.01). MACE (RR 0.75; 95 % CI 0.54-1.05; p = 0.09) and IDR (RR 0.41; 95 % CI 0.16-1.04; p = 0.06) were not significantly different between both strategies among those aged ≥65. However, there was a significant reduction in MI (RR 0.69; 95 % CI 0.49-0.96; p-value = 0.03), MACE (RR 0.78; 95 % CI 0.65-0.94; p < 0.01), and IDR (RR 0.60; 95 % CI 0.41-0.89; p < 0.01) in those aged ≥75.

CONCLUSIONS

In elderly patients aged ≥65 years with ACS and MVD, a strategy of complete revascularization by PCI reduces MI compared to culprit-only PCI with no significant difference in MACE and IDR. However, complete revascularization reduced MI, MACE, and IDR in those aged ≥75 years suggesting a possible benefit in this age group.

Timing of Complete Multivessel Revascularization in Acute Coronary Syndrome: 2-Year Results of the BIOVASC Study

BACKGROUND

In patients with acute coronary syndromes (ACS) and multivessel coronary disease, immediate complete revascularization was noninferior to staged complete revascularization for the primary composite outcome at 1 year. The authors report clinical outcomes at 2 years of follow-up.

METHODS

Patients with ACS and multivessel coronary disease were randomly assigned to immediate complete revascularization or to staged complete revascularization at 29 sites in Europe. The primary outcome was the composite of all-cause mortality, myocardial infarction, any unplanned ischemia-driven revascularization, and cerebrovascular event.

RESULTS

In total, 764 patients were enrolled and randomly allocated to the immediate complete revascularization arm and 761 to the staged complete revascularization arm. Two-year follow-up was complete for 97.6% of patients. At 2 years, the primary outcome had occurred in 12.5% of patients in the immediate complete revascularization group and 12.4% of patients in the staged complete revascularization group (HR: 0.98; 95% CI: 0.73-1.30; P = 0.88). Myocardial infarction occurred more frequently in the staged complete revascularization group (6.2% vs 3.8%; HR: 0.60; 95% CI: 0.37-0.96; P = 0.032). In the immediate complete revascularization and staged complete revascularization groups, the rates of all-cause mortality (3.3% vs 2.0%; HR: 1.67; 95% CI: 0.88-3.16; P = 0.12), any unplanned ischemia-driven revascularization (7.0% vs 7.9%; HR: 0.87; 95% CI: 0.60-1.26; P = 0.57), and cerebrovascular event (2.5% vs 1.7%; HR: 1.39; 95% CI: 0.68-2.83; P = 0.37) were not significantly different.

CONCLUSIONS

In patients with ACS and multivessel disease, there was no significant difference between immediate complete revascularization and staged complete revascularization with respect to the composite outcome of all-cause mortality, myocardial infarction, any unplanned ischemia-driven revascularization, and cerebrovascular event at 2 years. Immediate complete revascularization was associated with a significant reduction in myocardial infarction, mainly due to fewer early events. (Direct Complete Versus Staged Complete Revascularization in Patients Presenting With Acute Coronary Syndromes and Multivessel Disease [BioVasc]; NCT03621501).

Comparison of immediate and staged complete revascularization in patients with acute coronary syndrome and multivessel coronary disease: a systematic review and meta-analysis

BACKGROUND

The optimal timing of complete revascularization (CR) in patients with acute coronary syndrome (ACS) and multivessel disease (MVD) is still debated. The safety and efficacy of immediate and staged CR (ICR vs. SCR) in this patient group were thus compared.

METHODS AND RESULTS

PubMed, Embase, and CENTRAL were systematically searched to identify randomized controlled trials of CR strategies for MVD. Studies comparing cardiovascular benefits between ICR and SCR in ACS patients with MVD were included. Short- and long-term outcomes were compared using random-effect risk ratios (RRs). The analysis included seven studies with 3445 patients. The ICR and SCR groups showed comparable risks of all-cause death at 1 year (RR: 1.18; 95% CI: 0.72 to 1.95), but the risk increased at 1 month in ICR patients (RR: 2.35; 95% CI: 1.12 to 4.91). ICR reduced the risk of myocardial infarction (MI, RR: 0.54; 95% CI: 0.33 to 0.90) and target vessel revascularization (TVR, RR: 0.62; 95% CI: 0.45 to 0.85) at 1 year.

CONCLUSION

The all-cause death rates were comparable between ICR and SCR strategies. CR at index procedure could reduce MI and TVR rates at 1 year (46% and 38%, respectively). Future studies need to obtain more precise evidence and identify the cardiovascular benefits of these two strategies.

CLINICAL TRIAL NUMBER

Not applicable.

Staged versus immediate complete revascularization for non-culprit arteries in acute myocardial infarction: a post-hoc analysis of FRAME-AMI

Background and objectives

The optimal timing for complete revascularization (CR) in patients with acute myocardial infarction (AMI) and multivessel disease (MVD) remain uncertain.

Methods

This post-hoc analysis of the FRAME-AMI trial included AMI patients with MVD (n = 549). They were classified into immediate (n = 329) and staged CR (n = 220) groups. All percutaneous coronary interventions were performed during inex hospitalization. The primary endpoint was a composite of all-cause death, acute myocardial infarction, and repeated revascularization. Secondary endpoints included each component of the primary endpoint. Additional comparisons for the outcomes in ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) were also performed.

Results

The incidence of the primary endpoint was not significantly different in any of the AMI patients [12.7% [immediate CR] vs. 17.4% [staged CR], p = 0.905, adjusted hazard ratio [HR] of staged CR = 0.81, 95% confidence interval = 0.43-1.53, p = 0.528]. Other secondary endpoints were also not significantly different. Analyses of STEMI and Neither the primary or secondary endpoints of NSTEMI patients were significantly different.

Conclusions

In this post-hoc analysis of the FRAME-AMI trial, no significant difference in clinical outcomes was observed between the immediate and staged CR strategies for AMI with MVD and the subgroups, such as STEMI or NSTEMI. However, the results should be interpreted carefully because of the many limitations, including a limited sample size and a lack of statistical power. Trial Registration: FRAME-AMI clinicaltrials.gov, identifier (NCT02715518).

Meta-Analysis Comparing Immediate Versus Staged Complete Revascularization for ST-Elevation Myocardial Infarction With Multivessel Disease

Patients with ST-segment elevation myocardial infarction (STEMI) frequently present with multivessel coronary artery disease (CAD) during primary percutaneous coronary intervention, and the optimal timing of complete revascularization (CR) in these cases remains uncertain. This study aims to assess major adverse cardiovascular events (MACEs) and procedural complications in patients with STEMI with multivessel CAD who underwent immediate (index procedure) versus staged CR. We conducted a systematic review and meta-analysis of randomized controlled trials comparing immediate to staged CR in STEMI and multivessel CAD. Trials were identified by way of a systematic search of MEDLINE, Embase, and Cochrane Libraries from database inception to March 6, 2024. The data were analyzed using the RevMan software. A total of 5 randomized controlled trials (n = 1,415) were included in our study, which showed no significant differences in MACEs (13.3% vs 9.8%, relative risk [RR] 1.07, 95% confidence interval [CI] 0.62 to 1.83), all-cause mortality (3% vs 4.55%, RR 0.70, 95% CI 0.41 to 1.21), or myocardial infarction (4.5% vs 2.6%, RR 1.43, 95% CI 0.58 to 3.55) at a weighted mean follow-up duration of 16 months. However, the staged group had a higher rate of unplanned revascularization (8.6% vs 4.4%, RR 1.92, 95% CI 1.21 to 3.04). In conclusion, in patients with STEMI with multivessel CAD, at a mean follow-up of approximately 1.3 years, there is no significant difference in immediate versus staged revascularization (SR) for MACEs; however, SR was associated with a significantly higher incidence of unplanned ischemia-driven revascularization. SR within the index hospitalization may be as effective as immediate CR; further trials are needed to confirm this. Condensed Abstract We conducted a meta-analysis of 5 randomized controlled trials comparing immediate to staged complete revascularization in patients with ST-segment elevation myocardial infarction with multivessel coronary artery disease. There was no significant difference in major adverse cardiovascular events, all-cause mortality, and myocardial infarction rates between immediate and staged complete revascularization. However, staged revascularization was associated with a higher incidence of unplanned ischemia-driven revascularization.

Percutaneous coronary revascularization versus medical therapy in chronic coronary syndromes: An updated meta-analysis of randomized controlled trials

INTRODUCTION

Coronary artery disease (CAD) is a main cause of morbidity and mortality. The effectiveness of coronary revascularization in chronic coronary syndromes (CCS) is still debated. Our recent study showed the superiority of coronary revascularization over optimal medical therapy (OMT) in reducing cardiovascular (CV) mortality and myocardial infarction (MI). The recent publication of the ORBITA-2 trial suggested superiority of percutaneous coronary revascularization (PCI) in reducing angina and improving quality of life. Therefore, we aimed to provide an updated meta-analysis evaluating the impact of PCI on both clinical outcomes and angina in CCS.

METHODS

Relevant studies were screened in PubMed/Medline until 08/01/2024. Randomized controlled trials (RCTs) comparing PCI to OMT in CCS were selected. The primary outcome was CV death. Secondary outcomes were MI, all-cause mortality, stroke, major bleeding and angina severity.

RESULTS

Nineteen RCTs involving 8616 patients were included. Median follow-up duration was 3.3 years. Revascularization significantly reduced CV death (4.2% vs. 5.5%; OR = .77; 95% CI .62-.96, p = .02). Subgroup analyses favoured revascularization in patients without chronic total occlusions (CTOs) (p = .052) and those aged <65 years (p = .02). Finally, a follow-up duration beyond 3 years showed increased benefit of coronary revascularization (p = .04). Secondary outcomes analyses showed no significant differences, except for a lower angina severity in the revascularization group according to the Seattle Angina Questionnaire (SAQ) (p = .04) and to the Canadian Cardiovascular Society (CCS) classification (p = .005).

CONCLUSIONS

PCI compared to OMT significantly reduces CV mortality and angina severity, improving quality of life in CCS patients. This benefit was larger without CTOs, in patients aged <65 years and with follow-up duration beyond 3 years.

Complete versus culprit-only coronary revascularization in patients with myocardial infarction and multivessel disease undergoing percutaneous coronary intervention: an updated meta-analysis

INTRODUCTION

Recently, the FFR-Guidance for Complete Nonculprit Revascularization (FULL REVASC) trial in ST elevation myocardial infarction (STEMI) patients with multiple vessel disease (MVD) did not show differences in the composite endpoint of death from any cause, myocardial infarction, or unplanned revascularization than culprit-lesion-only percutaneous coronary intervention (PCI) at 4.8 years, although complete revascularization is a recommendation IA in current guidelines. We want to determine through an updated meta-analysis whether complete revascularization is associated with decreased mortality and hard clinical endpoints compared to culprit lesion only PCI.

EVIDENCE ACQUISITION

We searched MEDLINE, Embase, ISI Web of Science, and Cochrane Central Register of Controlled Trials) from January 1990 to April 2024 using the terms "percutaneous coronary intervention" combined with "non culprit lesions" or "culprit lesion" or "complete revascularization" or "incomplete revascularization." Additionally, a "snowball search" was conducted. Only randomized clinical trials (RCT) reporting mortality, re-infarction or new revascularization after at least 12 months and using predominantly drug eluting stents were included. The summary effect of different revascularization strategies on cardiovascular endpoints was estimated and measures of effect size were expressed as odds ratios (ORs).

EVIDENCE SYNTHESIS

Eight RCT involving 9515 patients were included, with a follow-up range between 12 months and 4.8 years. Main findings show that culprit lesion revascularization was associated with an increased risk of MI (OR: 1.38; 95% CI: 1.05 to 1.81, I2 42%) and ischemia-guided revascularization (OR: 2.81; 95% CI: 1.86 to 4.26, I2 80%) compared to complete revascularization, without differences in overall mortality (OR: 1.15; 95% CI: 0.98 to 1.36, I2 2%).

CONCLUSIONS

In patients with STEMI and MVD without cardiogenic shock, our metanalysis showed that complete revascularization with PCI significantly reduced the risk of non-fatal myocardial reinfarction and ischemic-driven revascularization compared to culprit vessel-only revascularization, without differences in overall mortality.

A Meta-Analysis of Timing of Complete Revascularization in Patients with ST-Elevation Myocardial Infarction

Background: Recent randomized clinical trials (RCTs) of STEMI patients with multi-vessel disease (MVD) reported potential superiority of immediate (ICR) vs. staged complete revascularization (SCR). Inherently, the risk of procedural MI is less likely to be detected in ICR patients, and this may have influenced the results. Recently published meta-analyses encompassed observational studies without including STEMI data from the BioVasc trial. The aim of this meta-analysis was to perform an updated comparison of the two strategies in STEMI patients with MVD. Methods: Electronic databases were searched from their inception till August 2024 to identify RCTs assessing CR timing in STEMI patients with MVD. Only studies with an endpoint involving major adverse cardiovascular events (MACE) were included. Results: Six RCTs totaling 2023 patients were included in the analysis. The median time to staged PCI was 19 days. The incidence of MACE (as defined by each study's protocol) was comparable between the two strategies [RR 0.86, 95% CI (0.58 to 1.27)]. There was also no difference in the risk of non-procedural MI [RR 0.91, 95% CI (0.49-1.67)], death [RR 1.47, 95% CI (0.89-2.44)] and cardiovascular death [RR 1.53, 95% CI (0.79-2.98)]. There was a significant 40% reduction in unplanned revascularization in patients undergoing ICR versus SCR [RR 0.60 (0.40 to 0.89), p = 0.01]. Conclusions: ICR reduced the risk of unplanned revascularization compared to SCR but had a comparable effect on MACE, death, cardiovascular death and non-procedural MI. Both strategies are safe in managing patients with acute MI and MVD.

Electrocardiographic findings for predicting the left anterior descending artery chronic total occlusion in patients with inferior ST-segment elevation myocardial infarction

In determining the culprit vessel responsible for inferior ST-segment elevation myocardial infarction (STEMI) as either the right coronary artery (RCA) or left circumflex (LCX), the electrocardiographic value has been validated. However, its ability to predict whether inferior STEMI is complicated by left anterior descending artery (LAD) chronic total occlusion remains uncertain. Based on the involvement of arteries other than the culprit vessels, 189 patients with inferior STEMI from our chest pain center were categorized into four groups: LAD occlusion group (n = 20), LAD stenosis > 50% group (n = 116), normal LAD group (n = 27), and other vessel stenosis > 50% group (n = 26). All groups underwent coronary angiography within 24 h of admission, and electrocardiogram (ECG) and clinical data were retrospectively analyzed. In the LAD occlusion group, hypertension was significantly more prevalent (P = 0.015). Although there was a trend toward higher previous cerebral infarction and lower diabetes prevalence in the Normal LAD group, neither was statistically significant (P = 0.070 and P = 0.088). The LAD occlusion group demonstrated the highest serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels and the most reduced LVEF, with a higher susceptibility to cardiogenic shock (P < 0.01). This group also had a higher use of intra-aortic balloon pump (IABP) and a greater occurrence of ventricular fibrillation or tachycardia compared to the other groups (P < 0.05). The QRS duration in lead V4 (QRS V4) was 99.4 ± 19.1 ms in the LAD occlusion group, 87.5 ± 14.9 ms in the LAD stenosis group, 89.6 ± 11.4 ms in the normal LAD group, and 87.7 ± 11.7 ms in the other vessel stenosis group (P = 0.010). The difference between ST-segment depression in V4 and ST-segment elevation in lead III (ST V4↓- ST III↑) in the LAD occlusion group was the largest at -0.06 (-1.19, 1.05) mm (P = 0.029). ROC curve analysis revealed that the sensitivity of QRS V4 > 97.7ms and ST V4↓- ST III↑> 0 mm diagnosing inferior STEMI complicated with LAD occlusion was 54.5% and 50%, with a specificity of 75.1% and 78.0%, respectively. Multivariate logistic regression analysis indicated that QRS V4 (OR = 1.062, P = 0.003), ST V4↓- ST III↑ (OR = 1.641, P = 0.050), and Killip classification (OR = 2.115, P = 0.004) were all independent risk factors for LAD occlusion. In patients with inferior STEMI complicated by LAD occlusion without anterior myocardial infarction, cardiac function is poorer. The ST-segment deviation between the leads V4 and III, and the duration of QRS in the lead V4, can aid in diagnosis.

Immediate Versus Staged Complete Revascularization for Patients With ST-Segment-Elevation Myocardial Infarction and Multivessel Disease: A Network Meta-Analysis of Randomized Trials

BACKGROUND

The comparative outcomes with immediate, staged in-hospital, and staged out-of-hospital complete revascularization for patients with ST-segment-elevation myocardial infarction and multivessel disease remain unclear.

METHODS AND RESULTS

An electronic search of MEDLINE, SCOPUS, and Cochrane databases was performed through August 2023 for randomized trials evaluating immediate, staged in-hospital, and staged out-of-hospital complete revascularization for patients with ST-segment-elevation myocardial infarction and multivessel disease. The primary outcome was major adverse cardiac events (MACEs). The final analysis included 9 trials with 4270 patients. The weighted follow-up duration was 13.8 months. On pairwise meta-analysis, there were no statistically significant differences between immediate versus staged nonculprit percutaneous coronary intervention (PCI) in MACEs (odds ratio, 0.79 [95% CI, 0.54-1.16]). Network meta-analysis showed that there was no statistically significant difference in MACEs with staged in-hospital nonculprit PCI (odds ratio, 1.29-[95% CI, 0.91-1.82]) compared with immediate nonculprit PCI, while there were higher odds of MACEs with out-of-hospital nonculprit PCI (odds ratio, 1.67-[95% CI, 1.21-2.30]) compared with immediate nonculprit PCI. Compared with immediate nonculprit PCI, there were higher odds of ischemia-driven repeat revascularization with staged out-of-hospital nonculprit PCI (odds ratio, 2.26-[95% CI, 1.37-3.72]), but not with in-hospital staged nonculprit PCI. There were no significant differences for the other outcomes among the 3 strategies.

CONCLUSIONS

Among patients with ST-segment-elevation myocardial infarction with multivessel disease, an immediate nonculprit PCI approach was associated with similar clinical outcomes to the staged nonculprit PCI approach. The staged out-of-hospital nonculprit PCI approach was associated with a higher incidence of MACEs compared with the other strategies, which was driven by higher risk for ischemia-driven repeat revascularization.

The Clinical Interpretation of Noninferiority Trials

Noninferiority trials are designed to demonstrate that a new treatment is not unacceptably worse than a standard treatment, considering an allowable difference termed the noninferiority margin. We highlight that selection of noninferiority margins at the time of study design can be biased toward wider margins that favor noninferiority claims. We discuss a clinically oriented approach to interpretation of results with a focus on confidence intervals and recommend that readers base their judgments regarding noninferiority on margins reflecting patient values and preferences rather than those set by investigators. We provide examples from trials in inflammatory bowel diseases.

SCAI Expert Consensus Statement on the Management of Patients With STEMI Referred for Primary PCI

ST-elevation myocardial infarction (STEMI) remains a leading cause of morbidity and mortality in the United States. Timely reperfusion with primary percutaneous coronary intervention is associated with improved outcomes. The Society for Cardiovascular Angiography & Interventions puts forth this expert consensus document regarding best practices for cardiac catheterization laboratory team readiness, arterial access with an algorithm to help determine proper arterial access in STEMI, and diagnostic angiography. This consensus statement highlights the strengths and limitations of various diagnostic and therapeutic interventions to access and treat a patient with STEMI in the catheterization laboratory, reviews different options to manage large thrombus burden during STEMI, and reviews the management of STEMI across the spectrum of various anatomical and clinical circumstances.

A Bayesian reanalysis of the CULPRIT-SHOCK trial

AIMS

The optimal revascularization strategy for patients with acute myocardial infarction (AMI), cardiogenic shock (CS), and multivessel disease remains controversial. The CULPRIT-SHOCK trial compared culprit lesion-only vs. immediate multivessel percutaneous coronary intervention (PCI), providing important data but leaving efficacy questions unresolved. To address lingering uncertainties and gain deeper insights, we performed a Bayesian reanalysis of the CULPRIT-SHOCK trial data.

METHODS AND RESULTS

We conducted a Bayesian re-analysis of the CULPRIT-SHOCK trial data using non-informative, sceptical, and enthusiastic priors. Relative risks (RRs) with 95% highest posterior density (HPD) intervals were calculated. We defined the minimal clinically important difference (MCID) as RR < 0.84. We performed subgroup analyses for key patient characteristics and assessed secondary outcomes and safety endpoints. Probabilities of benefit, achieving MCID, and harm were computed. Results are presented as median RR with probabilities of effect sizes. Bayesian reanalysis showed a median RR of 0.82 (95% HPD 0.66-1.04) with a non-informative prior, indicating a 95% probability of benefit and 59% probability of achieving MCID. Subgroup analyses revealed potentially stronger effects in males (RR 0.78, 73% probability of MCID), patients without diabetes (RR 0.76, 79% probability of MCID), and those with non-anterior ST-segment elevation MI (STEMI; RR 0.74, 76% probability of MCID). Secondary outcomes suggested potential benefits in mortality (RR 0.85) and need for renal replacement therapy (RR 0.72) but increased risks of recurrent MI (RR 2.84) and urgent revascularization (RR 2.88).

CONCLUSION

Our Bayesian reanalysis provides intuitive insights by quantifying probabilities of treatment effect sizes, offering further evidence favouring the culprit lesion-only PCI strategy in AMI patients with CS and multivessel disease. The analysis demonstrates a high probability of overall benefit, with a notable chance of achieving a minimally clinically important difference, particularly in specific subgroups. These findings not only support the consideration of culprit lesion-only PCI in certain patient populations but also underscore the need for careful risk-benefit assessment. Furthermore, our hypothesis-generating subgroup analyses, which show varying probabilities of achieving MCID, illuminate promising avenues for future targeted investigations in this critical patient population.

The alternative splicing landscape of infarcted mouse heart identifies isoform level therapeutic targets

Alternative splicing is an important process that contributes to highly diverse transcripts and protein products, which can affect the development of disease in various organisms. Cardiovascular disease (CVD) represents one of the greatest global threats to humans, particularly acute myocardial infarction (MI) and subsequent ischemic reperfusion (IR) injury, which involve complex transcriptomic changes in heart tissues associated with metabolic reshaping and immunological response. In this study, we used a newly developed ONT full-length transcriptomic approach and performed transcript-resolved differential expression profiling in murine models of MI and IR. We built an analytical pipeline to reliably identify and quantify alternative splicing products (isoforms), expanding on the currently available catalog of isoforms described in mice. The updated alternative splicing landscape included transcripts, genes, and pathways that were differentially regulated during IR and MI. Our study establishes a pipeline to profile highly diverse isoforms using state-of-the-art long-read sequencing, builds a landscape of alternative splicing in the mouse heart during MI and IR.

Association of triglyceride glucose index with clinical outcomes in ischemic stroke: a retrospective study

BACKGROUND

Stroke is a major cause of illness, death, and long-term disability and a major health concern worldwide. Experts consider insulin resistance (IR), a defining feature of the metabolic syndrome and a significant risk factor for stroke. Insulin resistance, or IR, is common among stroke patients. The triglyceride-glucose (TYG) index's relevance to both lipotoxicity and glucotoxicity has led to its proposal as an alternative indicator of IR.

AIM

Examining the connection between elevated TYG INDEX scores and worse clinical outcomes in ischemic stroke patients is the main goal. Finding out how often bad outcomes (recurrence and all-cause death) are in ischemic stroke patients is the secondary goal.

METHOD

This was a retrospective observational study that involved patients admitted to the 850-bed Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, a tertiary care teaching hospital located in the Krishna district of Andhra Pradesh (India). The study was conducted over a period of six months. All the 95 patients who satisfied the eligibility criteria were included. The patients' TYG INDEX values were first determined and patients with ischemic stroke who had elevated TYG INDEX values were then compared for clinical outcomes including recurrence and all-cause death with ischemic patients with normal TYG INDEX.

RESULTS

In this study, the total cholesterol of the patients (mean ± SD) was 165.01 ± 51.5 mg/dL; Triglycerides was 157.031 ± 98.9 mg/dL; HDL-c was 37.253 ± 5.52 mg/dl; LDL-c was 107 ± 48.3 mg/Dl; and FBS was 153.74 ± 71.52 mg/dL. The chi-square test showed that only FBS, Triglyceride, and Total cholesterol were significantly associated with TYG INDEX whereas other variables like age, LDL, and HDL were not. There was no significant association between the TYG INDEX and clinical outcomes of ischemic stroke. In both groups of patients, risk and no risk TYG INDEX values, the mRS score showed variable and unpredictable relationship with the TYG INDEX.

CONCLUSION

Contrary to the few studies that discovered one, our research leads us to the conclusion that there may not be a relevant association between the TYG INDEX and clinical results in patients with ischemic stroke.

CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS) in 2024

Primary Percutaneous Coronary Intervention (PCI) has significantly contributed to reducing the mortality of patients with ST-segment elevation myocardial infarction (STEMI) even in cardiogenic shock and is now the standard of care in most of Japanese institutions. The Task Force on Primary PCI of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) proposed an expert consensus document for the management of acute myocardial infarction (AMI) focusing on procedural aspects of primary PCI in 2018 and updated in 2022. Recently, the European Society of Cardiology (ESC) published the guidelines for the management of acute coronary syndrome in 2023. Major new updates in the 2023 ESC guideline include: (1) intravascular imaging should be considered to guide PCI (Class IIa); (2) timing of complete revascularization; (3) antiplatelet therapy in patient with high-bleeding risk. Reflecting rapid advances in the field, the Task Force on Primary PCI of the CVIT group has now proposed an updated expert consensus document for the management of ACS focusing on procedural aspects of primary PCI in 2024 version.

Coronary bypass surgery for multivessel disease after percutaneous coronary intervention in acute coronary syndromes: why, for whom, how early?

Multivessel coronary artery disease is present in ∼50% of patients with acute coronary syndrome and, compared with single-vessel disease, entails a higher risk of new ischaemic events and a worse prognosis. Randomized controlled trials have shown the superiority of 'complete revascularization' over culprit lesion-only treatment. Trials, however, only included patients treated with percutaneous coronary intervention (PCI), and evidence regarding complete revascularization with coronary artery bypass graft (CABG) surgery after culprit lesion-only PCI ('hybrid revascularization') is lacking. The CABG after PCI is an open, non-negligible therapeutic option, for patients with non-culprit left main and/or left anterior descending coronary artery disease where evidence in chronic coronary syndrome patients points in several cases to a preference of CABG over PCI. This valuable but poorly studied 'PCI first-CABG later' option presents, however, relevant challenges, mostly in the need of interrupting post-stenting dual antiplatelet therapy (DAPT) for surgery to prevent excess bleeding. Depending on patients' clinical characteristics and coronary anatomical features, either deferring surgery after a safe interruption of DAPT or bridging DAPT interruption with intravenous short-acting antithrombotic agents appears to be a suitable option. Off-pump minimally invasive surgical revascularization, associated with less operative bleeding than open-chest surgery, may be an adjunctive strategy when revascularization cannot be safely deferred and DAPT is not interrupted. Here, the rationale, patient selection, optimal timing, and adjunctive strategies are reviewed for an ideal approach to hybrid revascularization in post-acute coronary syndrome patients to support physicians' choices in a case-by-case patient-tailored approach.

Impact of Immediate Versus Staged Complete Revascularization on Short-Term and Long-Term Clinical Outcomes in Patients With Acute Coronary Syndrome and Multivessel Disease: A Systematic Review and Meta-Analysis

BACKGROUND

In patients with acute coronary syndrome (ACS) and multivessel disease (MVD), complete revascularization (CR) improves prognosis. This meta-analysis, summarizing recent RCTs, contrasts short-term and long-term clinical outcomes between immediate complete revascularization (ICR) and staged complete revascularization (SCR).

METHODS

We systematically searched the online database and eight RCTs were involved. The primary outcomes included long-term unplanned ischemia-driven revascularization, re-infarction, combined cardiovascular (CV) death or myocardial infarction (MI), all-cause death, CV death, stroke, and hospitalization for heart failure (HHF). The secondary outcomes were 1-month unplanned ischemia-driven revascularization, re-infarction, all-cause death, and CV death. Safety endpoints included stent thrombosis and major bleeding.

RESULTS

Eight RCTs comprising 5198 patients were involved. ICR reduced long-term unplanned ischemia-driven revascularization (RR 0.64, 95% CI 0.51-0.81, p < 0.001), combined CV death or MI (HR 0.51, 95% CI 0.34-0.78, p = 0.002), and re-infarction (RR 0.66,95% CI 0.48 to 0.91, p = 0.012) compared with SCR. ICR also decreased 1-month unplanned ischemia-driven revascularization (RR 0.41, 95% CI: 0.21-0.77, p = 0.006) and re-infarction (RR 0.33, 95% CI:0.15-0.74, p = 0.007) but increased 1-month all-cause death (RR 2.22, 95% CI 1.06-4.65, p = 0.034).

CONCLUSION

In ACS patients with MVD, we first found that ICR significantly lowered the risk of both short-term and long-term unplanned ischemia-driven revascularization and re-infarction, as well as the long-term composite outcome of CV death or MI compared with SCR. However, there may be an increase in 1-month all-cause death in the ICR group.

Optimal Timing of Angiography-Guided Complete Revascularization of Non-Culprit Lesions in STEMI Patients with Multivessel Disease

Background: There are many questions regarding the optimal approach to treating non-culprit lesions in STEMI patients. Several questions still need to be answered, such as identifying the lesions to be revascularized and the optimal timing. Methods: We conducted a single-center analysis. The primary outcome was the incidence of major cardiovascular and cerebral adverse events (MACCE) at 12 months in patients with STEMI and multivessel disease (MVD) who achieved complete revascularization during the index procedure or with a staged procedure. The secondary outcomes were death from any cause, myocardial infarction, target lesion revascularization, stroke, major bleeding events, new angina episodes, new hospitalization, and in-hospital MACCE. Results: From January 2021 to December 2022, a total of 230 patients with STEMI underwent primary PCI in our department; 87 patients had MVD. Fifty-nine patients (67.8%) underwent a non-culprit revascularization strategy during the index procedure strategy, and 28 patients (32.2%) during a staged procedure. The incidence of MACCE at 12 months was 11.9% (seven patients) in the index PCI group, compared with 32.1% (nine patients) in the staged PCI group (odds ratio, 3.52; 95% CI, 1.15 to 10.77; p = 0.022). In-hospital MACCE occurred in five patients (8.5%) of the index PCI group, compared with seven patients (25%) in the staged PCI group (odds ratio, 3.60; 95% CI, 1.03 to 12.61; p = 0.036). A trend towards better outcomes favoring the index PCI group was observed with death from any cause, myocardial infarction, target lesion revascularization, and new angina episodes. Conclusions: Better outcomes were evident with an index PCI strategy than with a staged PCI strategy for complete revascularization in patients with STEMI and MVD.

An observational study of therapeutic procedures and in-hospital outcomes among patients admitted for acute myocardial infarction in Spain, 2016-2022: the role of diabetes mellitus

BACKGROUND

We used the Spanish national hospital discharge data from 2016 to 2022 to analyze procedures and hospital outcomes among patients aged ≥ 18 years admitted for ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) according to diabetes mellitus (DM) status (non-diabetic, type 1-DM or type 2-DM).

METHODS

We built logistic regression models for STEMI/NSTEMI stratified by DM status to identify variables associated with in-hospital mortality (IHM). We analyzed the effect of DM on IHM.

RESULTS

Spanish hospitals reported 201,950 STEMIs (72.7% non-diabetic, 0.5% type 1-DM, and 26.8% type 2-DM; 26.3% female) and 167,285 NSTEMIs (61.6% non-diabetic, 0.6% type 1-DM, and 37.8% type 2-DM; 30.9% female). In STEMI, the frequency of percutaneous coronary intervention (PCI) increased among non-diabetic people (60.4% vs. 68.6%; p < 0.001) and people with type 2-DM (53.6% vs. 66.1%; p < 0.001). In NSTEMI, the frequency of PCI increased among non-diabetic people (43.7% vs. 45.7%; p < 0.001) and people with type 2-DM (39.1% vs. 42.8%; p < 0.001). In NSTEMI, the frequency of coronary artery by-pass grafting (CABG) increased among non-diabetic people (2.8% vs. 3.5%; p < 0.001) and people with type 2-DM (3.7% vs. 5.0%; p < 0.001). In the entire population, lower IHM was associated with undergoing PCI (odds ratio [OR] [95% confidence interval] = 0.34 [0.32-0.35] in STEMI; 0.24 [0.23-0.26] in NSTEMI) or CABG (0.33 [0.27-0.40] in STEMI; 0.45 [0.38-0.53] in NSTEMI). IHM decreased over time in STEMI (OR = 0.86 [0.80-0.93]). Type 2-DM was associated with higher IHM in STEMI (OR = 1.06 [1.01-1.11]).

CONCLUSIONS

PCI and CABG were associated with lower IHM in people admitted for STEMI/NSTEMI. Type 2-DM was associated with IHM in STEMI.

The Year in Cardiology—Practice Changing Trials from European Society of Cardiology Congress 2023

The European Society of Cardiology annual congress is the premier global platform for dissemination and unraveling major scientific advances in the field of cardiology. Each year a myriad number of scientific ideas are exchanged at this meeting and many major path-breaking clinical trials are presented that have the potential to alter our practice. Last year was not different and more than 30 clinical trials spanning various facets of cardiology were unveiled and discussed—heart failure, lipid lowering, coronary intervention, intracoronary imaging, cardiomyopathies, anticoagulation, atrial fibrillation, antiplatelet therapy, etc. We present a brief summary of 10 major trials which in the view of authors have the potential for impacting daily cardiology practice. In each study, we also attempt to provide a contemporary perspective and the way forward. We aim to provide a glimpse on the major advances in the field of cardiology in the past year.

Acute myocardial infarction and ischaemic stroke: differences and similarities in reperfusion therapies-a review

Acute ST-elevation myocardial infarction (STEMI) and acute ischaemic stroke (AIS) share a number of similarities. However, important differences in pathophysiology demand a disease-tailored approach. In both conditions, fast treatment plays a crucial role as ischaemia and eventually infarction develop rapidly. Furthermore, in both fields, the introduction of fibrinolytic treatments historically preceded the implementation of endovascular techniques. However, in contrast to STEMI, only a minority of AIS patients will eventually be considered eligible for reperfusion treatment. Non-invasive cerebral imaging always precedes cerebral angiography and thrombectomy, whereas coronary angiography is not routinely preceded by non-invasive cardiac imaging in patients with STEMI. In the late or unknown time window, the presence of specific patterns on brain imaging may help identify AIS patients who benefit most from reperfusion treatment. For STEMI, a uniform time window for reperfusion up to 12 h after symptom onset, based on old placebo-controlled trials, is still recommended in guidelines and generally applied. Bridging fibrinolysis preceding endovascular treatment still remains the mainstay of reperfusion treatment in AIS, while primary percutaneous coronary intervention is the strategy of choice in STEMI. Shortening ischaemic times by fine-tuning collaboration networks between ambulances, community hospitals, and tertiary care hospitals, optimizing bridging fibrinolysis, and reducing ischaemia-reperfusion injury are important topics for further research. The aim of this review is to provide insights into the common as well as diverging pathophysiology behind current reperfusion strategies and to explore new ways to enhance their clinical benefit.

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.

Immediate vs. multistage revascularization of non-infarct coronary artery(-ies) in patients with hemodynamically stable multivessel disease acute myocardial infarction: a systematic review and meta-analysis

BACKGROUND

Untreated multivessel disease (MVD) in acute myocardial infarction (AMI) has been linked to a higher risk of recurrent ischemia and death within one year . Current guidelines recommend percutaneous coronary intervention (PCI) for significant non-infarct artery (-ies) (non-IRA) stenosis in hemodynamically stable AMI patients with MVD, either during or after successful primary PCI, within 45-days. However, deciding the timing of revascularization for non-IRA in cases of MVD is uncertain.

METHODS

This meta-analysis was performed based on PRISMA guidelines after registering in PROSPERO (CRD42023472652). Databases were searched for relevant articles published before 10 November 2023. Pertinent data from the included studies were extracted and analyzed using RevMan v5.4.

RESULTS

Out of 640 studies evaluated, there were 13 RCTs with 5144 patients with AMI with MVD. The immediate non-IRA PCI is associated with a significantly lower occurrence of unplanned ischemia-driven PCI (OR 0.60; confidence interval [CI] 0.44-0.83) and target-vessel revascularization (OR 0.72; CI 0.53-0.97) . Although there is a favorable trend for major adverse cardiovascular and cerebrovascular events (MACCE), nonfatal AMI, cerebrovascular events, and major bleeding in the immediate non-culprit artery (-ies) PCI, those were statistically non-significant. Similarly, all-cause mortality, cardiovascular mortality, stent thrombosis, and acute renal insufficiency did not show significant differences between two groups.

CONCLUSION

Among hemodynamically stable patients with multivessel AMI, the immediate PCI strategy was superior to the multistage PCI strategy for the unplanned ischemia-driven PCI and target-vessel revascularization while odds are favorable in terms of MACCE, nonfatal AMI, cerebrovascular events, and major bleeding at longest follow-up.

Percutaneous Coronary Revascularization Strategies After Myocardial Infarction: A Systematic Review and Network Meta-Analysis

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.

Timing of Complete Revascularization Stratified by Index Presentation During On- and Off-Hours

Recent trials suggested immediate complete revascularization (ICR) as a safe alternative to staged complete revascularization (SCR), but the impact of the respective percutaneous coronary intervention strategies between on- versus off-hours is unclear. On-hours was defined as an index revascularization performed between 8:00 a.m. and 6:00 p.m., Monday to Friday, or else the procedure was defined as performed during off-hours. The primary end point consisted of a composite of all-cause mortality, myocardial infarction, unplanned ischemia-driven revascularization, and cerebrovascular events at 1-year follow-up. We used Cox regression models to relate randomized treatment with study end points. We evaluated multiplicative and additive interactions between on- versus off-hours and randomized treatment. The BIOVASC (Percutaneous Complete Revascularization Strategies Using Sirolimus Eluting Biodegradable Polymer Coated Stents in Patients Presenting With Acute Coronary Syndromes and Multivessel Disease) trial enrolled 1,097 and 428 patients during on- and off-hours, respectively. Patients randomized during off-hours were more likely to present with ST-segment elevation myocardial infarction (66.4% vs 29.5%, p <0.001). The composite primary outcome occurred in 8.4% and 10.1% of patients randomized to ICR and SCR, respectively, during on-hours (hazard ratio 0.80, 95% confidence interval 0.54 to 1.19). During off-hours, the primary composite outcome occurred in 5.4% and 7.7% in ICR and SCR (0.69, 95% confidence interval 0.32 to 1.46) with no evidence of a differential effect (interaction pmultiplicative = 0.70, padditive = 0.56). No differential effect was found between treatment allocation and on- versus off-hours in any of the secondary outcomes. In conclusion, no differential treatment effect was found when comparing ICR versus SCR in patients presenting with acute coronary syndrome and multivessel disease during on- or off-hours.

Immediate versus staged complete revascularisation in patients presenting with STEMI and multivessel disease

BACKGROUND

Complete revascularisation is supported by recent trials in patients with ST-elevation myocardial infarction (STEMI) and multivessel disease (MVD) without cardiogenic shock. However, the optimal timing of non-culprit lesion revascularisation is currently debated.

AIMS

This prespecified analysis of the BioVasc trial aims to determine the effect of immediate complete revascularisation (ICR) compared to staged complete revascularisation (SCR) on clinical outcomes in patients with STEMI.

METHODS

Patients presenting with STEMI and MVD were randomly assigned to ICR or SCR. The primary endpoint was the composite of all-cause mortality, myocardial infarction, any unplanned ischaemia-driven revascularisation, or cerebrovascular events at 1-year post-index procedure.

RESULTS

Between June 2018 and October 2021, 608 (ICR: 305, SCR: 303) STEMI patients were enrolled. No significant differences between ICR and SCR were observed at 1-year follow-up in terms of the primary endpoint (7.0% vs 8.3%, hazard ratio [HR] 0.84, 95% confidence interval [CI]: 0.47-1.50; p=0.55): all-cause mortality (2.3% vs 1.3%, HR 1.77, 95% CI: 0.52-6.04; p=0.36), myocardial infarction (1.7% vs 3.3%, HR 0.50, 95% CI: 0.17-1.47; p=0.21), unplanned ischaemia-driven revascularisation (4.1% vs 5.0%, HR 0.80, 95% CI: 0.38-1.71; p=0.57) and cerebrovascular events (1.4% vs 1.3%, HR 1.01, 95% CI: 0.25-4.03; p=0.99). At 30-day follow-up, a trend towards a reduction of the primary endpoint in the ICR group was observed (ICR: 3.0% vs SCR: 6.0%, HR 0.50, 95% CI: 0.22-1.11; p=0.09). ICR was associated with a reduction in overall hospital stay (ICR: median 3 [interquartile range {IQR} 2-5] days vs SCR: median 4 [IQR 3-6] days; p<0.001).

CONCLUSIONS

Clinical outcomes at 1 year were similar for STEMI patients who had undergone ICR and those who had undergone SCR.

Emerging Evidence in Out-of-Hospital Cardiac Arrest-A Critical Appraisal of the Cardiac Arrest Center

The morbidity and mortality of out-of-hospital cardiac arrest (OHCA) due to presumed cardiac causes have remained unwaveringly high over the last few decades. Less than 10% of patients survive until hospital discharge. Treatment of OHCA patients has traditionally relied on expert opinions. However, there is growing evidence on managing OHCA patients favorably during the prehospital phase, coronary and intensive care, and even beyond hospital discharge. To improve outcomes in OHCA, experts have proposed the establishment of cardiac arrest centers (CACs) as pivotal elements. CACs are expert facilities that pool resources and staff, provide infrastructure, treatment pathways, and networks to deliver comprehensive and guideline-recommended post-cardiac arrest care, as well as promote research. This review aims to address knowledge gaps in the 2020 consensus on CACs of major European medical associations, considering novel evidence on critical issues in both pre- and in-hospital OHCA management, such as the timing of coronary angiography and the use of extracorporeal cardiopulmonary resuscitation (eCPR). The goal is to harmonize new evidence with the concept of CACs.

Managing the Intricacies of Coronary Revascularization: A Close Look at the Complete Versus Culprit-Only Approach and its Implications in Elderly Patients

Coronary heart disease is the leading cause of mortality in the United States, and data indicates that 805,000 Americans will face a new or recurrent myocardial infarction (MI) attack every year. Frailty, a conceptual syndrome categorized by a functional decline that occurs with aging, has been linked to adverse health outcomes in cardiovascular disease and all cardiac-related procedures in general. It is therefore reasonable to deliberate that more conservative medical therapy or medical management should be considered in the frail population when managing acute coronary syndrome. This course of action has, in fact, been documented in clinical practice. However, the recent Functional Assessment in Elderly MI Patients with Multivessel Disease trial, in which all subjects were 75 years of age or above, indicated that the more invasive complete revascularization approach may be favorable over incomplete or culprit-only revascularization in patients with acute MI. In this review, we will discuss coronary heart disease and review guidelines and procedures for culprit lesion identification, including electrocardiogram procedures, coronary angiography, intravascular ultrasound, fractional flow reserve, and instantaneous fractional flow reserve. We then discuss the concept of complete vs culprit-only/incomplete coronary revascularization and staging. Following this, we will delve into recent trials discussing complete vs culprit-only revascularization, emphasizing the insights gleaned from this latest trial within this special frailty cohort which warrants special consideration.

Where Are We With Treatment and Prevention of Heart Failure in Patients Post-Myocardial Infarction?

As a result of the widespread use of reperfusion therapies and secondary prevention over the last 30 years, there has been a dramatic reduction in the risk of mortality and development of heart failure (HF) following acute myocardial infarction (MI). Despite this, the development of chronic HF remains a common occurrence in the days, months, and years following MI. Neurohormonal inhibition remains the mainstay of pharmacologic prevention of HF following MI, with recent trials showing an additive benefit of a neprilysin inhibitor or a sodium glucose co-transporter 2 inhibitor in reducing the risk of development of HF but no significant effect on mortality. Novel imaging tools may help refine risk stratification in high-risk patients and allow greater targeting of preventative therapies in patients most likely to benefit. Research is ongoing into novel therapies aiming to minimize the degree of myocardial damage and prevention of progressive adverse remodeling following MI.

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

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.

Advances in Clinical Cardiology 2023: A Summary of Key Clinical Trials

INTRODUCTION

Over the course of 2023, numerous key clinical trials with valuable contributions to clinical cardiology were published or presented at major international conferences. This review seeks to summarise these trials and reflect on their clinical context.

METHODS

The authors collated and reviewed clinical trials presented at major cardiology conferences during 2023 including the American College of Cardiology (ACC), European Association for Percutaneous Cardiovascular Interventions (EuroPCR), European Society of Cardiology (ESC), Transcatheter Cardiovascular Therapeutics (TCT), American Heart Association (AHA), European Heart Rhythm Association (EHRA), Society for Cardiovascular Angiography and Interventions (SCAI), TVT-The Heart Summit (TVT) and Cardiovascular Research Technologies (CRT). Trials with a broad relevance to the cardiology community and those with potential to change current practice were included.

RESULTS

A total of 80 key cardiology clinical trials were identified for inclusion. Key trials in acute coronary syndrome (ACS) and antiplatelet management such as HOST-IDEA, T-PASS and STOP-DAPT3 were included in addition to several pivotal interventional trials such as ORBITA 2, MULTISTARS-AMI, ILUMIEN-IV, OCTIVUS and OCTOBER. Additionally, several trials evaluated new stent design and technology such as BIOSTEMI, PARTHENOPE and TRANSFORM. Structural intervention trials included long-term data from PARTNER 3, new data on the durability of transcatheter aortic valve intervention (TAVI), in addition to major new trials regarding transcatheter tricuspid valve intervention from TRISCEND II. Heart failure (HF) and prevention covered several key studies including DAPA-MI, STEP-HF, ADVOR, DICTATE HF and CAMEO-DAPA. In cardiac devices and electrophysiology, several trial exploring novel ablation strategies in atrial fibrillation (AF) such as PULSED AF and ADVENT were presented with further data evaluating the efficacy of anticoagulation in subclinical AF in NOAH-AFNET 6, FRAIL AF and AZALEA-TIMI 71.

CONCLUSION

This article presents a summary of key clinical cardiology trials published and presented during the past year and should be of interest to both practising clinicians and researchers.

Culprit-Only Revascularization, Single-Setting Complete Revascularization, and Staged Complete Revascularization in Acute Myocardial Infarction: Insights From a Mixed Treatment Comparison Meta-Analysis of Randomized Trials

BACKGROUND

Complete revascularization improves cardiovascular outcomes compared with culprit-only revascularization in patients with acute myocardial infarction ([MI]; ST-segment-elevation MI or non-ST-segment-elevation MI) and multivessel coronary artery disease. However, the timing of complete revascularization (single-setting versus staged revascularization) is uncertain. The aim was to compare the outcomes of single-setting complete, staged complete, and culprit vessel-only revascularization in patients with acute MI and multivessel disease.

METHODS

PubMed, EMBASE, and clinicaltrials.gov databases were searched for randomized controlled trials that compared 3 revascularization strategies.

RESULTS

From 16 randomized controlled trials that randomized 11 876 patients with acute MI and multivessel disease, both single-setting complete and staged complete revascularization reduced primary outcome (cardiovascular mortality/MI; odds ratio [OR], 0.52 [95% CI, 0.41-0.65]; OR, 0.74 [95% CI, 0.62-0.88]), composite of all-cause mortality/MI (OR, 0.52 [95% CI, 0.40-0.67]; OR, 0.78 [95% CI, 0.67-0.91]), major adverse cardiovascular event (OR, 0.42 [95% CI, 0.32-0.56]; OR, 0.62 [95% CI, 0.47-0.82]), MI (OR, 0.39 [95% CI, 0.26-0.57]; OR, 0.73 [95% CI, 0.59-0.90]), and repeat revascularization (OR, 0.30 [95% CI, 0.18-0.47]; OR, 0.46 [95% CI, 0.30-0.71]) compared with culprit-only revascularization. Single-setting complete revascularization reduced cardiovascular mortality/MI (OR, 0.70 [95% CI, 0.55-0.91]), major adverse cardiovascular event (OR, 0.67 [95% CI, 0.50-0.91]), and all-cause mortality/MI driven by a lower risk of MI (OR, 0.53 [95% CI, 0.36-0.77]) compared with staged complete revascularization. Single-setting complete revascularization ranked number 1, followed by staged complete revascularization (number 2) and culprit-only revascularization (number 3) for all outcomes. The results were largely consistent in subgroup analysis comparing ST-segment-elevation MI versus non-ST-segment-elevation MI cohorts.

CONCLUSIONS

Single-setting complete revascularization may offer the greatest reductions in cardiovascular events in patients with acute MI and multivessel disease. A large-scale randomized trial of single-setting complete versus staged complete revascularization is warranted to evaluate the optimal timing of complete revascularization.

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

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.

Immediate Versus Staged Complete Revascularization in Patients With Acute Coronary Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

A strategy of complete revascularization (CR) is recommended in patients with acute coronary syndrome (ACS) and multivessel disease (MVD). However, the optimal timing of CR remains equivocal. We searched MEDLINE, Embase, the Cochrane Library, and ClinicalTrials.gov for randomized controlled trials (RCTs) comparing immediate CR (ICR) with staged CR in patients with ACS and MVD. Our primary outcomes were all-cause and cardiovascular mortality. All outcomes were assessed at 3 time points: in-hospital or at 30 days, at 6 months to 1 year, and at >1 year. Data were pooled in RevMan 5.4 using risk ratios as the effect measure. A total of 9 RCTs (7,506 patients) were included in our review. A total of 7 trials enrolled patients with ST-segment elevation myocardial infarction (STEMI), 1 enrolled patients with non-STEMI only, and 1 enrolled patients with all types of ACS. There was no difference between ICR and staged CR regarding all-cause and cardiovascular mortality at any time window. ICR reduced the rate of myocardial infarction and decreased the rate of repeat revascularization at 6 months and beyond. The rates of cerebrovascular events and stent thrombosis were similar between the 2 groups. In conclusion, the present meta-analysis demonstrated a lower rate of myocardial infarction and a reduction in repeat revascularization at and after 6 months with ICR strategy in patients with mainly STEMI and MVD. The 2 groups had no difference in the risk of all-cause and cardiovascular mortality. Further RCTs are needed to provide more definitive conclusions and investigate CR strategies in other ACS.