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Vacha J, Spacek M, Kaminek M, Hutyra M, Nykl R, Sluka M, Taborsky M. Comparison of myocardial perfusion study and invasive hemodynamic measurement of the significance of non-infarct-related residual stenoses in ST elevation myocardial infarction patients. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2024. [PMID: 38916126 DOI: 10.5507/bp.2024.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND Nearly 50% of ST elevation myocardial infarction (STEMI) patients have multivessel coronary artery disease. The optimal selection of non-culprit lesions for complete revascularization is a matter of current debate. Little is known about the predictive value of myocardial perfusion study (MPS) in this scenario. METHODS We enrolled 49 STEMI patients (61.5 ± 10.3 years) with at least one major non-culprit lesion (50-90%) other than left main coronary artery lesions. Overall 63 non-infarct- related artery (IRA) stenoses (65.2 ± 11.9%) were recommended for further evaluation using Fractional Flow Reserve (FFR) measurement as is standard in our institution. Prior to FFR, all patients were scheduled for non-invasive MPS using single-photon emission computed tomography (SPECT). Both FFR and MPS were performed 4-8 weeks after STEMI with MPS preceding FFR within no more than 48 hours. An FFR value of ≤0.80 was considered significant and guided the final revascularization strategy. The results of MPS were correlated to FFR as well as to the clinical and angiographic characteristics of both culprit and non-infarct-related lesions. RESULTS Based on FFR, 30 out of 63 stenoses (47.6%) in 27 patients were considered hemodynamically significant (FFR 0.69 ± 0.08, range 0.51-0.79) compared to residual 33 stenoses considered negative (FFR 0.87 ± 0.04, range 0.81-0.96). The MPS revealed abnormal myocardium (23.6% average, range 5-56%) in 21 patients (42.8%). Among those patients, only 9 showed the evidence of ischemic myocardium (average 10.8%, range 4-18%) with low sensitivity of MPS in predicting positive FFR. Besides that, higher proportion of patients (71.4% vs. 42.9%, P=0.047) with overall lower FFR values (0.73 vs. 0.80, P=0.014, resp.) in non-IRAs as well as higher proportion of patients with more severely compromised flow in IRAs (P=0.048) during STEMI had MPS-detected abnormal myocardium. CONCLUSION In STEMI patients with multivessel coronary artery disease, we observed rather weak correlation between MPS using SPECT and invasive hemodynamic measurement using FFR in ischemia detection.
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Affiliation(s)
- Jan Vacha
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Miloslav Spacek
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Milan Kaminek
- Department of Nuclear Medicine, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Martin Hutyra
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Radomir Nykl
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Martin Sluka
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Milos Taborsky
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
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Abdelhafez MA, Aly KME, Youssef AAA. Effect of residual myocardial ischemia on recovery of left ventricular function after primary percutaneous coronary intervention. BMC Cardiovasc Disord 2024; 24:164. [PMID: 38504186 PMCID: PMC10949644 DOI: 10.1186/s12872-024-03777-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 02/08/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND It is unknown whether the existence of severe bystander damage will affect left ventricular (LV) healing following primary percutaneous coronary intervention (PPCI). The aim of the present analysis was to follow LV recovery using 2D speckle tracking echocardiography (2-D STE) in cases with single versus multiple vessel disease with acute myocardial infarction (AMI) who underwent PPCI and to assess major adverse cardiovascular events (MACEs) within 3 months. PATIENTS AND METHODS This work was conducted at Assiut University Heart Hospital. Of 1026 screened subjects with AMI needing PPCI and assessed for eligibility, only 89 cases fulfilled the inclusion criteria. They were classified into Group A: single vessel and Group B: multiple vessel (≥ 2 vessels) disease. Their data were obtained on admittance and after 90 days. RESULTS In group A compared to group B, there was a statistically preferable value at baseline in the global longitudinal strain- Apical 2 chamber (GLS-A2C) (-12.05 ± 3.57 vs. -10.38 ± 3.92, P = 0.039). At follow-up, the improvement was in all 2-D STE variables, including GLS-long axis (GLS-LAX) (-13.09 ± 3.84 vs.-10.75 ± 3.96, P = 0.006), GLS- apical 4 chamber (GLS-A4C) (-13.23 ± 3.51 vs.-10.62 ± 4.08, P = 0.002), GLS-A2C (-13.85 ± 3.41 vs-10.93 ± 3.97, P < 0.001) and GLS- average (GLS-AVG, P = 0.001). There was a considerable negative correlation between the recovery of LV performance and the existence of multi-vessel lesions (P = 0.009). There was no variance between the groups regarding MACEs. CONCLUSIONS Patients with single vessel lesions who underwent PPCI to the culprit lesion had better recovery of LV function than those with multi-vessel (≥ 2 vessels) lesions who underwent PPCI to the culprit lesion only. The presence of multivessel involvement was an independent risk factor for deterioration in GLS. TRIAL REGISTRATION Registered in clinical trial, clinicalTrial.gov ID NCT04103008 (25/09/2019). IRB registration: 17,100,834 (05/11/2019).
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Affiliation(s)
| | - Karim M E Aly
- Demonstrator of Cardiology, Faculty of Medicine, Assiut University, Assiut, 71515, Egypt.
| | - Amr A A Youssef
- Professor of Cardiology, Faculty of Medicine, Assiut University, Assiut, 17575, Egypt
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Spacek M, Vacha J, Kaminek M, Hutyra M, Nykl R, Sluka M, Taborsky M. Comparison of angiographic estimation and invasive hemodynamic measurement of the significance of non-infarct-related residual stenoses in ST-elevation myocardial infarction patients. Arch Med Sci Atheroscler Dis 2023; 8:e169-e176. [PMID: 38283928 PMCID: PMC10811533 DOI: 10.5114/amsad/172971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 09/27/2023] [Indexed: 01/30/2024] Open
Abstract
Introduction Up to 50% of patients with ST elevation myocardial infarction (STEMI) have ≥ 50% stenosis in a major non-infarct-related artery. Several studies have evaluated the prognostic value of the completion of revascularization with overall inconclusive results. Selection of the stenoses was based on the angiographic evaluation, invasive hemodynamic measurement or the combined approach. It is unknown whether such a selection provides correlation of comparable patient groups. Material and methods We enrolled 51 patients (62.7 ±10.2 years) with acute STEMI and at least one residual (50-90%) stenosis in a non-infarct-related major coronary artery (excluding left main coronary artery). Overall 65 stenoses (67.9 ±10.7%) were evaluated angiographically following primary percutaneous coronary intervention and the hemodynamic significance was estimated with respect to the stenosis severity, caliber of the arterial segment, localization of the stenosis (proximity) as well as the estimated size of the supplied vascular territory. During subsequent hospitalization, invasive measurement of the hemodynamic significance using fractional flow reserve (FFR) was performed to guide the final revascularization strategy (FFR value of ≤ 0.80 considered significant). Results Based on angiographic evaluation, a total of 44 stenoses would be recommended for treatment, whereas only 31 stenoses were revascularized based on FFR measurement. Moreover, visual evaluation and hemodynamic measurement were discrepant in 27 of 65 (41.5%) stenoses. Conclusions We observed a weak correlation between visual angiographic evaluation and invasive hemodynamic measurement. More stents would be implanted based on angiographic evaluation compared to FFR measurement.
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Affiliation(s)
- Miloslav Spacek
- Department of Internal Medicine I – Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Jan Vacha
- Department of Internal Medicine I – Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Milan Kaminek
- Department of Nuclear Medicine, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Martin Hutyra
- Department of Internal Medicine I – Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Radomir Nykl
- Department of Internal Medicine I – Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Martin Sluka
- Department of Internal Medicine I – Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Milos Taborsky
- Department of Internal Medicine I – Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
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Spacek M, Vacha J, Precek J, Hutyra M, Nykl R, Sluka M, Taborsky M. Complete revascularization of multivessel coronary artery disease in patients with ST elevation acute coronary syndrome - for whom and when? A comprehensive review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2023; 167:16-23. [PMID: 35703363 DOI: 10.5507/bp.2022.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/17/2022] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Miloslav Spacek
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Jan Vacha
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Jan Precek
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Martin Hutyra
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Radomir Nykl
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Martin Sluka
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Milos Taborsky
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
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Rai D, Tahir MW, Bandyopadhyay D, Chowdhury M, Kharsa A, Pendala VS, Ali H, Naidu SS, Baibhav B. Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials for Multivessel PCI Versus Culprit Artery Only PCI in STEMI Without Cardiogenic Shock. Curr Probl Cardiol 2020; 46:100646. [PMID: 32650950 DOI: 10.1016/j.cpcardiol.2020.100646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/07/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Traditionally ST-elevation myocardial infarction (STEMI) with multivessel coronary artery disease is treated with percutaneous coronary intervention (PCI) to culprit lesion only. The benefit of multivessel (MV) PCI among STEMI patients without cardiogenic shock is unclear. METHODS PubMed, EMBASE, and Cochrane Database were searched from 1996 to 2019, for studies of patients with STEMI without cardiogenic shock, who underwent PCI. Only randomized controlled trials comparing culprit PCI to MV PCI vs culprit vessel PCI were included for pairwise meta-analysis. All-cause mortality, cardiac mortality, reinfarction, revascularization and major adverse cardiovascular events (MACE) were compared. Trial sequential analysis (TSA) was performed for outcome variables. RESULTS Nine randomized controlled trials contributed 6930 patients meeting inclusion criteria. Three thousand three hundred seventy-six underwent MV PCI, and 3554 underwent culprit PCI. Our analysis demonstrated no significant difference in all-cause mortality. MV PCI had a lower risk of cardiac mortality, reinfarction, MACE and repeat revascularization compared to culprit PCI (P values <0.05). TSA showed futility for further trials to detect all-cause mortality benefit and lack of firm evidence of benefit in cardiac mortality and re-infarction, but firm evidence of benefit in revascularization and MACE. CONCLUSIONS In conclusion, MV PCI strategy was beneficial in reducing cardiac mortality, reinfarction, repeat revascularization, and MACE but there was no all-cause mortality benefit when compared to culprit only PCI strategy. Evidence for benefit in cardiac mortality and re-infarction is not robust per TSA.
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Metaanalysis of Multivessel vs Culprit Artery Only Percutaneous Coronary Intervention in ST Elevation Myocardial Infarction. Ochsner J 2019; 19:107-115. [PMID: 31258422 DOI: 10.31486/toj.18.0033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: Primary percutaneous coronary intervention (PCI) is the most frequently used treatment modality for patients presenting with ST elevation myocardial infarction (STEMI). Current professional society guidelines recommend culprit artery only PCI. Recent evidence suggests the potential benefit of multivessel PCI among patients with STEMI that is not complicated by cardiogenic shock. Methods: We systematically searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials for clinical studies of patients with STEMI, not complicated by cardiogenic shock, who underwent primary PCI between January 1966 and January 2018. We evaluated all-cause and cardiovascular mortality, reinfarction, and repeat revascularization among patients randomized to a multivessel PCI strategy compared to a culprit artery only PCI strategy. Results: Four randomized clinical trials with a total of 1,044 patients met the inclusion criteria. Five hundred and sixty-six patients underwent multivessel PCI, and 478 patients underwent culprit artery only PCI. Multivessel PCI reduced all the studied endpoints: total death, cardiac death, reinfarction, and repeat revascularization (all P values <0.05). Conclusion: To our knowledge, this is the largest metaanalysis of randomized controlled trials studying multivessel PCI vs culprit artery only PCI in STEMI patients without shock, among whom lesion severity was graded by angiography alone. We found that compared to culprit artery only PCI, the multivessel PCI strategy was beneficial in reducing all-cause and cardiovascular mortality, reinfarction, and the need for repeat revascularization.
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Complete Versus Culprit-Only Revascularization in STEMI: a Contemporary Review. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:41. [PMID: 29627944 DOI: 10.1007/s11936-018-0636-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW In ST-segment elevation myocardial infarction, urgent revascularization of the culprit coronary vessel and restoration of coronary flow is the goal of the initial management. However, obstructive non-culprit disease is frequently concomitantly found during initial angiography and portends a poor prognosis. Management of non-culprit lesions in ST-segment elevation myocardial infarction (STEMI) has been the subject of extensive debate. This review will examine the currently available evidence, with a specific focus on randomized clinical trials performed to date. RECENT FINDINGS Although early observational data suggested better outcomes with culprit-only revascularization, more recent data from several randomized trials have suggested improved outcomes with complete multivessel revascularization, either during the index PCI procedure or as a staged procedure. Data from recent randomized controlled trials have suggested the superiority of complete or multivessel revascularization and have subsequently led to changes to the most recent iterations of STEMI guidelines. However, the optimal management and timing of revascularization of non-culprit lesions in STEMI remain controversial.
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Hasun M, Weidinger F. Culprit Vessel Only Versus Complete Revascularisation in Patients with ST-Segment Elevation Myocardial Infarction – Should we Stay or Stage? Interv Cardiol 2018; 13:129-134. [DOI: 10.15420/icr.2018.13.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Multivessel coronary artery disease (MVCAD) is common in patients with ST-elevation myocardial infarction (STEMI), thereby negatively affecting mortality and outcome. Currently there is increasing evidence that complete revascularisation should be considered in haemodynamically stable patients. There are few larger randomised controlled trials available showing a lower risk of major adverse cardiac events after complete revascularisation, mainly driven by a reduction of repeat revascularisation. However, these trials are not adequately powered to show a mortality benefit or reduced risk of myocardial infarction. As there are several possible strategies, the presence of MVCAD often poses a therapeutic dilemma for interventional cardiologists and there is still ongoing debate on when and how to perform complete revascularisation. Pending further trials that may clarify which strategy is best, an individualised approach should be adopted.
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Andries G, Khera S, Timmermans RJ, Aronow WS. Complete versus culprit only revascularization in ST-elevation myocardial infarction-a perspective on recent trials and recommendations. J Thorac Dis 2017; 9:2159-2167. [PMID: 28840017 DOI: 10.21037/jtd.2017.06.95] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The presence of multivessel coronary artery disease (CAD) is strongly associated with higher 30-day mortality, reduced myocardial reperfusion success, reinfarction, and occurrence of major adverse cardiac events (MACE) at 1 year compared with single-vessel CAD. Despite higher morbidity and mortality in patients with ST-elevation myocardial infarction (STEMI) and coexistent multivessel CAD, major guidelines recommended against percutaneous coronary intervention (PCI) on non-culprit lesions at the time of primary PCI in patients with STEMI who are hemodynamically stable. The presence of multivessel CAD often poses a therapeutic dilemma for interventional cardiologists. A few larger scale randomized controlled trials (RCTs) and meta-analyses have been conducted. The conclusions regarding multivessel PCI generally trend towards lower risk of MACE, repeat revascularization, with similar risks of recurrent myocardial infarction (MI) and mortality. However, none of the RCTs were adequately powered for hard outcomes of death and MI.
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Affiliation(s)
- Gabriela Andries
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Sahil Khera
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA.,Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Robert J Timmermans
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Wilbert S Aronow
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
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Tarantini G, D’Amico G, Brener SJ, Tellaroli P, Basile M, Schiavo A, Mojoli M, Fraccaro C, Marchese A, Musumeci G, Stone GW. Survival After Varying Revascularization Strategies in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Artery Disease. JACC Cardiovasc Interv 2016; 9:1765-76. [DOI: 10.1016/j.jcin.2016.06.012] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 05/17/2016] [Accepted: 06/05/2016] [Indexed: 01/12/2023]
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Bates ER, Tamis-Holland JE, Bittl JA, O’Gara PT, Levine GN. PCI Strategies in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Artery Disease. J Am Coll Cardiol 2016; 68:1066-81. [DOI: 10.1016/j.jacc.2016.05.086] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/19/2016] [Accepted: 05/10/2016] [Indexed: 12/19/2022]
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Abstract
Primary PCI of infarct-related arteries is the preferred reperfusion strategy in patients presenting with ST-segment elevation myocardial infarction (STEMI). Up to 40 % of such patients demonstrate evidence of multivessel, non-infarct-related artery coronary disease. Previous non-randomised observational studies and their associated meta-analyses have suggested that in such cases only the culprit infarct-related artery (IRA) lesion should be treated. However, recent randomised controlled trials have demonstrated improved clinical outcomes with lower major adverse cardiovascular events (MACE) rates when complete revascularisation is undertaken either at index primary percutaneous coronary intervention (PPCI) or during index admission. These trials suggest that current guidelines pertaining to treatment of non-infarct-related artery (N-IRA) lesions in STEMI patients with multivessel disease may need to be reconsidered depending on future trials. However, issues remain around timing of N-IRA intervention, the use of fractional flow reserve (FFR) or intravascular imaging to guide intervention in N-IRA lesions and the need to demonstrate reductions in hard clinical endpoints (death and MI) after complete revascularisation; these issues will need to be addressed through future trials. Clinicians must judge on the currently available data, whether it is still safer to leave important stenosis in N-IRA untreated.
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Affiliation(s)
- Amerjeet S. Banning
- />Department of Cardiovascular Sciences, University of Leicester Glenfield Hospital, Groby Road, Leicester, LE3 9QP UK
| | - Anthony H. Gershlick
- />Department of Cardiovascular Sciences, University of Leicester Glenfield Hospital, Groby Road, Leicester, LE3 9QP UK
- />Department of Cardiology, University Hospitals of Leicester NHS Trust Glenfield Hospital, Groby Road, Leicester, LE3 9QP UK
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Di Pasquale G, Filippini E, Pavesi PC, Tortorici G, Casella G, Sangiorgio P. Complete versus culprit-only revascularization in ST-elevation myocardial infarction and multivessel disease. Intern Emerg Med 2016; 11:499-506. [PMID: 26951188 DOI: 10.1007/s11739-016-1419-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 02/18/2016] [Indexed: 02/04/2023]
Abstract
In 30-60 % of patients presenting with ST-segment elevation myocardial infarction (STEMI), significant stenoses are present in one or more non-infarct-related arteries (IRA). This correlates with an increased risk of major adverse cardiac events (MACE). Current guidelines, do not recommend revascularization of non-culprit lesions unless complicated by cardiogenic shock or persistent ischemia after primary percutaneous coronary intervention (PCI). Prior observational and small randomized controlled trials (RCTs) have demonstrated conflicting results regarding the optimal revascularization strategy in STEMI patients with multivessel disease. Recently, randomized studies (PRAMI, CvLPRIT, and DANAMI 3-PRIMULTI) provide encouraging data that suggest potential benefit with complete revascularization in STEMI patients with obstructive non-culprit lesions. Differently, in the PRAGUE-13 trial there were no differences in MACE between complete revascularization and culprit-only PCI. Several meta-analyses were recently published including randomized and non-randomized clinical trials, showing different results depending on the included trials. In conclusion, the current available evidence from the randomized clinical trials, with a total sample size of only 2000 patients, is not robust enough to firmly recommend complete revascularization in STEMI patients. This uncertainty lends support to the continuation of the COMPLETE trial. This ongoing trial is anticipated to enroll 3900 patients with STEMI from across the world, and will be powered for the hard outcomes of death and myocardial infarction. Until the results of the COMPLETE trial are reported, physicians need to individualize care regarding the opportunity and the timing of the non-IRA PCI.
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Affiliation(s)
- Giuseppe Di Pasquale
- Division of Cardiology, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy.
| | - Elisa Filippini
- Division of Cardiology, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Pier Camillo Pavesi
- Division of Cardiology, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Gianfranco Tortorici
- Division of Cardiology, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Gianni Casella
- Division of Cardiology, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Pietro Sangiorgio
- Division of Cardiology, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy
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Managing Multivessel Coronary Artery Disease in Patients With ST-Elevation Myocardial Infarction: A Comprehensive Review. Cardiol Rev 2016; 25:179-188. [PMID: 27124268 DOI: 10.1097/crd.0000000000000110] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Multivessel coronary artery disease (CAD) is found in up to 60% of the patients presenting with an ST-elevation myocardial infarction (STEMI) and worsens the prognosis proportional to the extent of CAD severity. However, the 2013 American College of Cardiology/American Heart Association STEMI guidelines, based on mostly observational data, had recommended against a routine noninfarct-related artery percutaneous coronary intervention (PCI). After these guidelines were published, a handful of randomized trials became available, and they suggested that PCI of significant lesions in a noninfarct-related artery at the time of primary PCI might result in improved patient outcomes. The incidence of major adverse cardiac events was significantly reduced by 55% at 1 year and 65% at 2 years in patients undergoing angiographically guided PCI of nonculprit vessels at the time of primary PCI, in 2 different randomized trials. Fractional flow reserve-guided PCI of nonculprit vessels in this setting has also been shown to reduce cardiac events by 44% at 1 year. Meta-analyses of both nonrandomized and randomized trials have also suggested that complete revascularization at the time of STEMI significantly improves outcomes, including long-term all-cause mortality. In view of the emerging data, a focused update on primary PCI was published in 2015 and suggested that PCI of noninfarct-related arteries might be considered in selected patients. This article is a comprehensive review of the literature on the treatment of multivessel CAD in patients with STEMI, which provides the reader a critical analysis of the available information to determine the best therapeutic approach.
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Jang JS, Spertus JA, Arnold SV, Shafiq A, Grodzinsky A, Fendler TJ, Salisbury AC, Tang F, McNulty EJ, Grantham JA, Cohen DJ, Amin AP. Impact of multivessel revascularization on health status outcomes in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease. J Am Coll Cardiol 2016; 66:2104-2113. [PMID: 26541921 DOI: 10.1016/j.jacc.2015.08.873] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 08/21/2015] [Accepted: 08/25/2015] [Indexed: 01/24/2023]
Abstract
BACKGROUND Up to 65% of patients with ST-segment elevation myocardial infarction (STEMI) have multivessel coronary artery disease (MVCAD). Long-term health status of STEMI patients after multivessel revascularization is unknown. OBJECTIVES This study investigated the relationship between multivessel revascularization and health status outcomes (symptoms and quality of life [QoL]) in STEMI patients with MVCAD. METHODS Using a U.S. myocardial infarction registry and the Seattle Angina Questionnaire (SAQ), we determined the health status of patients with STEMI and MVCAD at the time of STEMI and 1 year later. We assessed the association of multivessel revascularization during index hospitalization with 1-year health status using multivariable linear regression analysis, and also examined demographic, clinical, and angiographic factors associated with multivessel revascularization. RESULTS Among 664 STEMI patients with MVCAD, 251 (38%) underwent multivessel revascularization. Most revascularizations were staged during the index hospitalization (64.1%), and 8.0% were staged after discharge, with 27.9% performed during primary percutaneous coronary intervention. Multivessel revascularization was associated with age and more diseased vessels. At 1 year, multivessel revascularization was independently associated with improved symptoms (4.5 points higher SAQ angina frequency score; 95% confidence interval [CI]: 1.0 to 7.9) and QoL (6.6 points higher SAQ QoL score; 95% CI: 2.7 to 10.6). One-year mortality was not different between those who did and did not undergo multivessel revascularization (3.6% vs. 3.4%; log-rank test p = 0.88). CONCLUSIONS Multivessel revascularization improved angina and QoL in STEMI patients with MVCAD. Patient-centered outcomes should be considered in future trials of multivessel revascularization.
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Affiliation(s)
- Jae-Sik Jang
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri; Department of Cardiology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - John A Spertus
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri.
| | - Suzanne V Arnold
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Ali Shafiq
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Anna Grodzinsky
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Timothy J Fendler
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Adam C Salisbury
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Fengming Tang
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Edward J McNulty
- Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, California
| | - J Aaron Grantham
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - David J Cohen
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Amit P Amin
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri; Barnes-Jewish Hospital, St. Louis, Missouri
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Bajaj NS, Kalra R, Aggarwal H, Ather S, Gaba S, Arora G, McGiffin DC, Ahmed M, Aslibekyan S, Arora P. Comparison of Approaches to Revascularization in Patients With Multivessel Coronary Artery Disease Presenting With ST-Segment Elevation Myocardial Infarction: Meta-analyses of Randomized Control Trials. J Am Heart Assoc 2015; 4:e002540. [PMID: 26667087 PMCID: PMC4845262 DOI: 10.1161/jaha.115.002540] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 10/23/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Significant controversy exists regarding the best approach for nonculprit vessel revascularization in patients with multivessel coronary artery disease presenting with ST-segment elevation myocardial infarction. We conducted a systematic investigation to pool data from current randomized controlled trials (RCTs) to assess optimal treatment strategies in this patient population. METHODS AND RESULTS A comprehensive search of SCOPUS from inception through May 2015 was performed using predefined criteria. We compared efficacy and safety outcomes of different approaches by categorizing the studies into 3 groups: (1) complete revascularization (CR) versus culprit lesion revascularization (CL) at index hospitalization, (2) CR at index hospitalization versus staged revascularization (SR) of nonculprit vessels at a separate hospitalization, and (3) comparison of SR versus CL. Eight eligible RCTs met the inclusion criteria: (1) CR versus CL (6 RCTs, n=1727) (2) CR versus SR (3 RCTs, n=311), and (3) SR versus CL (1 RCT, n=149). We observed significantly lower rates of major adverse cardiovascular events, revascularization, and repeat percutaneous coronary interventions among patients treated with CR and SR compared with a CL approach (P<0.05). The rates of all-cause mortality, cause-specific mortality, major bleeding, reinfarction, stroke, and contrast-induced nephropathy did not differ in the CR arm compared with the CL arm. The rates of these outcomes were similar in the CR and SR arms. CONCLUSION Results suggest that CR and SR compared with CL reduce major adverse cardiovascular event and revascularization rates primarily by lowering repeated percutaneous coronary intervention rates. We did not observe any increase in the rate of adverse events while using a CR or SR strategy compared with a CL approach. Current guidelines discouraging CR need to be reevaluated, and clinical judgment should prevail in treating multivessel coronary artery disease patients with ST-segment elevation myocardial infarction as data from larger RCTs accumulate.
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Affiliation(s)
- Navkaranbir S. Bajaj
- Division of CardiologyDepartment of MedicineUniversity of Alabama at BirminghamAL
- Ryals School of Public HealthDepartment of EpidemiologyUniversity of Alabama at BirminghamAL
| | - Rajat Kalra
- Department of MedicineUniversity of Alabama at BirminghamAL
| | - Himanshu Aggarwal
- Division of CardiologyDepartment of MedicineUniversity of Alabama at BirminghamAL
| | - Sameer Ather
- Division of CardiologyDepartment of MedicineUniversity of Alabama at BirminghamAL
| | - Saurabh Gaba
- Division of CardiologyDepartment of MedicineUniversity of Alabama at BirminghamAL
| | - Garima Arora
- Division of CardiologyDepartment of MedicineUniversity of Alabama at BirminghamAL
| | | | - Mustafa Ahmed
- Division of CardiologyDepartment of MedicineUniversity of Alabama at BirminghamAL
- Division of CardiologyBaptist PrincetonBirminghamAL
| | - Stella Aslibekyan
- Ryals School of Public HealthDepartment of EpidemiologyUniversity of Alabama at BirminghamAL
| | - Pankaj Arora
- Division of CardiologyDepartment of MedicineUniversity of Alabama at BirminghamAL
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Russo JJ, Wells GA, Chong AY, So DY, Glover CA, Froeschl MP, Hibbert B, Marquis JF, Dick A, Blondeau M, Bernick J, Labinaz M, Le May MR. Safety and Efficacy of Staged Percutaneous Coronary Intervention During Index Admission for ST-Elevation Myocardial Infarction With Multivessel Coronary Disease (Insights from the University of Ottawa Heart Institute STEMI Registry). Am J Cardiol 2015; 116:1157-62. [PMID: 26282725 DOI: 10.1016/j.amjcard.2015.07.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 07/14/2015] [Accepted: 07/14/2015] [Indexed: 12/15/2022]
Abstract
The optimal management strategy for patients with ST-elevation myocardial infarction (STEMI) and multivessel disease has not been well established. In the present cohort study, we sought to examine the safety and efficacy of inhospital staged PCI for patients with STEMI and multivessel disease. We identified all patients with STEMI referred for primary PCI who were found to have multivessel disease (stenosis ≥50% in nonculprit vessel) and compared clinical outcomes in relation to the management strategy, staged versus culprit-only PCI, for nonculprit vessel disease. The primary outcome was mortality at 180 days, and secondary outcomes included mortality during the index hospitalization and at 30 days, myocardial infarction, stent thrombosis, stroke, and bleeding. Of the 1,038 patients with STEMI meeting inclusion criteria, 259 (25%) underwent staged PCI and 779 (75%) culprit-only PCI during the index admission. Mortality at 180 days was 0.8% in patients with staged PCI and 5.0% in patients with culprit-only PCI (p = 0.003). The association between staged PCI and reduced mortality persisted after adjusting for baseline differences in patient characteristics and angiographic variables between the 2 cohorts (odds ratio 0.2, 95% confidence interval 0.04 to 0.77, p = 0.02). The rates of inhospital reinfarction in the staged and culprit-only PCI cohorts were 0.8% versus 1.3% (p = 0.50), respectively, stent thrombosis 0.8% versus 1.3% (p = 0.50), and stroke 0.4% versus 1.3% (p = 0.31). There were no inhospital adverse events related to acute occlusion of a nonculprit vessel in either cohort. Staged PCI during index admission is a safe and effective revascularization strategy for patients with STEMI and multivessel disease.
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SONG YEOJEONG, SHIN HOCHEOL, YANG JOOII, LEE HOYOUNG, JIN HANYOUNG, SEO JEONGSOOK, YANG TAEHYUN, KIM DAEKYEONG, KIM DONGSOO, JANG JAESIK. Preventive versus Culprit-Only Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction Patients with Multivessel Disease: A Meta-Analysis. J Interv Cardiol 2015; 28:1-13. [DOI: 10.1111/joic.12167] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- YEO-JEONG SONG
- Department of Cardiology; Inje University Busan Paik Hospital; Busan Korea
| | - HO-CHEOL SHIN
- Department of Cardiology; Inje University Busan Paik Hospital; Busan Korea
| | - JOO-II YANG
- Department of Cardiology; Inje University Busan Paik Hospital; Busan Korea
| | - HO-YOUNG LEE
- Department of Cardiology; Inje University Busan Paik Hospital; Busan Korea
| | - HAN-YOUNG JIN
- Department of Cardiology; Inje University Busan Paik Hospital; Busan Korea
| | - JEONG-SOOK SEO
- Department of Cardiology; Inje University Busan Paik Hospital; Busan Korea
| | - TAE-HYUN YANG
- Department of Cardiology; Inje University Busan Paik Hospital; Busan Korea
| | - DAE-KYEONG KIM
- Department of Cardiology; Inje University Busan Paik Hospital; Busan Korea
| | - DONG-SOO KIM
- Department of Cardiology; Inje University Busan Paik Hospital; Busan Korea
| | - JAE-SIK JANG
- Department of Cardiology; Inje University Busan Paik Hospital; Busan Korea
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Moretti C, D'Ascenzo F, Quadri G, Omedè P, Montefusco A, Taha S, Cerrato E, Colaci C, Chen SL, Biondi-Zoccai G, Gaita F. Management of multivessel coronary disease in STEMI patients: A systematic review and meta-analysis. Int J Cardiol 2015; 179:552-7. [PMID: 25453403 DOI: 10.1016/j.ijcard.2014.10.035] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 08/04/2014] [Accepted: 10/18/2014] [Indexed: 02/05/2023]
Affiliation(s)
- Claudio Moretti
- Division of Cardiology, Department of Internal Medicine, Città Della Salute e Della Scienza, University of Turin, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Internal Medicine, Città Della Salute e Della Scienza, University of Turin, Italy.
| | - Giorgio Quadri
- Division of Cardiology, Department of Internal Medicine, Città Della Salute e Della Scienza, University of Turin, Italy
| | - Pierluigi Omedè
- Division of Cardiology, Department of Internal Medicine, Città Della Salute e Della Scienza, University of Turin, Italy
| | - Antonio Montefusco
- Division of Cardiology, Department of Internal Medicine, Città Della Salute e Della Scienza, University of Turin, Italy
| | - Salma Taha
- Division of Cardiology, Department of Internal Medicine, Città Della Salute e Della Scienza, University of Turin, Italy
| | - Enrico Cerrato
- Division of Cardiology, Department of Internal Medicine, Città Della Salute e Della Scienza, University of Turin, Italy
| | - Chiara Colaci
- Division of Cardiology, Department of Internal Medicine, Città Della Salute e Della Scienza, University of Turin, Italy
| | | | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Piazzale Aldo Moro, Rome, Italy
| | - Fiorenzo Gaita
- Division of Cardiology, Department of Internal Medicine, Città Della Salute e Della Scienza, University of Turin, Italy
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de Paula JGR, de Godoy MF, dos Santos MA, Pivatelli FC, Osti AVG, Trindade LF, Novelli D, Nakazone MA. Management of multivessel coronary disease after primary angioplasty: staged reintervention versus optimized clinical treatment and two-year follow-up. Braz J Cardiovasc Surg 2014; 29:177-85. [PMID: 25140467 PMCID: PMC4389456 DOI: 10.5935/1678-9741.20140051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 02/26/2014] [Indexed: 11/20/2022] Open
Abstract
Objective In the clinical scenario of ST-segment elevation acute myocardial infarction,
several patients with multivessel coronary atherosclerotic disease are discharged
without a defined strategy to monitor the residual atherosclerotic lesions. The
clinical endpoints evaluated were cardiovascular death, symptoms of angina
pectoris, rehospitalization for a new acute coronary syndrome, and the necessity
of reintervention during the two-year follow-up. Methods This observational, prospective, and historical study included multivessel
coronary atherosclerotic disease patients who were admitted to a tertiary care
university hospital with ST-segment elevation acute myocardial infarction and
underwent primary percutaneous coronary intervention with stent implantation only
at the culprit lesion site; these patients were monitored in the outpatient clinic
according to two treatments: the Clinical Group - CG (optimized pharmacological
therapy associated with counseling for a healthy diet and cardiac rehabilitation)
or the Intervention Group - IG (new staged percutaneous coronary intervention or
surgical coronary artery bypass graft surgery combined with the previously
prescribed treatment). Results Of 143 patients consecutively admitted with ST-segment elevation acute myocardial
infarction, 57 were eligible for the study (CG=44 and IG=13). Regarding the
clinical endpoints, the cardiovascular death rate did not differ between the CG
and IG. The symptom of angina pectoris and the rehospitalization rate for a new
episode of acute coronary syndrome were accentuated in the CG
(P=0.020 and P=0.049, respectively) mainly in
individuals with evidence of ischemia evidenced by myocardial scintigraphy
(P<0.001 and P=0.001, respectively) which
culminated in an even greater need for reintervention (P=0.001)
in this subgroup of patients. Conclusion The staged intervention was demonstrated to be safe and able to reduce angina
pectoris and rehospitalization for a new episode of acute coronary syndrome. In
addition, it decreases the likelihood of unplanned reinterventions of patients
without ischemia evidenced by myocardial scintigraphy.
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Affiliation(s)
- José Guilherme Rodrigues de Paula
- Correspondence address: José Guilherme Rodrigues de Paula, Hospital de
Base de S. José do Rio Preto - Laboratório de Hemodinâmica e Cardiologia
Intervencionista, Av. Brigadeiro Faria Lima, 5544, São José do Rio Preto, SP, Brazil,
Zip code: 15090-000. E-mail:
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Cuisset T, Noc M. Multivessel PCI in STEMI: ready to be the recommended strategy? EUROINTERVENTION 2014; 10 Suppl T:T47-54. [DOI: 10.4244/eijv10sta9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Kim MC, Jeong MH, Kim SH, Hong YJ, Kim JH, Ahn Y. Current Status of Coronary Intervention in Patients with ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Artery Disease. Korean Circ J 2014; 44:131-8. [PMID: 24876852 PMCID: PMC4037633 DOI: 10.4070/kcj.2014.44.3.131] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Primary percutaneous coronary intervention (PCI) is a standard interventional treatment modality for ST-segment elevation myocardial infarction (STEMI). Diagnostic coronary angiogram during PCI reveals multivessel coronary artery disease in about half of patients with STEMI, and it is difficult to make decision on the extent of intervention in these patients. Although revascularization for the infarct-related artery only is still effective for STEMI patients, several studies have reported the efficacy of multivessel revascularization during primary PCI, as well as in a staged PCI procedure. Clinicians should consider clinical aspects such as initial cardiogenic shock and myocardial viability when performing primary multivessel intervention, including the risks and benefits of multivessel revascularization in patients undergoing primary PCI. This review describes the current status of performing multivessel PCI in patients with STEMI and proposes an optimal revascularization strategy based on the previous literature.
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Affiliation(s)
- Min Chul Kim
- Department of Cardiovascular Medicine, Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Myung Ho Jeong
- Department of Cardiovascular Medicine, Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Sang Hyung Kim
- Department of Cardiovascular Medicine, Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Young Joon Hong
- Department of Cardiovascular Medicine, Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Ju Han Kim
- Department of Cardiovascular Medicine, Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Youngkeun Ahn
- Department of Cardiovascular Medicine, Heart Center, Chonnam National University Hospital, Gwangju, Korea
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Manari A, Varani E, Guastaroba P, Menozzi M, Valgimigli M, Menozzi A, Magnavacchi P, Franco N, Marzocchi A, Casella G. Long-term outcome in patients with ST segment elevation myocardial infarction and multivessel disease treated with culprit-only, immediate, or staged multivessel percutaneous revascularization strategies: Insights from the REAL registry. Catheter Cardiovasc Interv 2014; 84:912-22. [DOI: 10.1002/ccd.25374] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 12/02/2013] [Accepted: 12/21/2013] [Indexed: 12/11/2022]
Affiliation(s)
- Antonio Manari
- Interventional Cardiology Unit; Azienda Ospedaliera S. Maria Nuova - IRCCS Reggio Emilia Italy
| | - Elisabetta Varani
- Division of Cardiology and Interventional Center; Ospedale S. Maria delle Croci Ravenna Italy
| | - Paolo Guastaroba
- Regional Health Care Agency; Regione Emilia-Romagna Bologna Italy
| | - Mila Menozzi
- Interventional Cardiology Unit; Azienda Ospedaliera S. Maria Nuova - IRCCS Reggio Emilia Italy
| | - Marco Valgimigli
- Cardiovascular Institute; Azienda Ospedaliero-Universitaria S. Anna Ferrara Italy
| | - Alberto Menozzi
- Division of Cardiology and Cardiac Catheterization Laboratory; Azienda Ospedaliero-Universitaria; Parma Italy
| | - Paolo Magnavacchi
- Division of Cardiology and Cardiac Catheterization Laboratory; Nuovo Ospedale Civile S. Agostino-Estense; Modena Italy
| | - Nicoletta Franco
- Division of Cardiology and Cardiac Catheterization Laboratory; Ospedale Infermi; Rimini Italy
| | - Antonio Marzocchi
- Institute of Cardiology, Azienda Ospedaliero-Universitaria Policlinico S. Orsola-Malpighi; Bologna Italy
| | - Gianni Casella
- Division of Cardiology and Cardiac Catheterization Laboratory; Ospedale Maggiore; Bologna Italy
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Bainey KR, Mehta SR, Lai T, Welsh RC. Complete vs culprit-only revascularization for patients with multivessel disease undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: a systematic review and meta-analysis. Am Heart J 2014; 167:1-14.e2. [PMID: 24332136 DOI: 10.1016/j.ahj.2013.09.018] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 09/30/2013] [Indexed: 12/28/2022]
Abstract
BACKGROUND Patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease who undergo primary percutaneous coronary intervention (PCI) are most commonly treated with PCI to the culprit lesion only. Whether a strategy of complete revascularization in these patients is superior is unknown. We performed a meta-analysis comparing the benefits and risks of routine culprit-only PCI vs multivessel PCI in STEMI. METHODS MEDLINE, EMBASE, ISI Web of Science, and The Cochrane Register of Controlled Trials were searched from 1996 to January 2011. Relevant conference abstracts were searched from January 2002 to January 2011. Studies included STEMI with multivessel disease receiving primary PCI. The primary end point was long-term mortality. Data were combined using a fixed-effects model. RESULTS Of 507 citations, 26 studies (3 randomized, 23 nonrandomized; 46,324 patients, 7886 multivessel PCI and 38,438 culprit-only PCI) were included. There was no significant difference in hospital mortality with multivessel PCI vs culprit-only PCI (odds ratio [OR] 1.11, 95% CI 0.98-1.25, P = .10 [randomized OR 0.24, 95% CI 0.06-0.91, P = .04; nonrandomized OR 1.12, 95% CI 1.00-1.27, P = .06]). However, if multivessel PCI during index catheterization was performed, hospital mortality was increased (OR 1.35, 95% CI 1.19-1.54, P < .001). When multivessel PCI was performed as a staged procedure, hospital mortality was lower (OR 0.35, 95% CI 0.21-0.59; P < .001; P interaction < .001). Reduced long-term mortality (OR 0.74, 95% CI 0.65-0.85, P < .001[randomized OR 0.61, 95% CI 0.28-1.33, P = .22; nonrandomized OR 0.75, 95% CI 0.65-0.86, P < .001]) and repeat PCI (OR 0.65; 95% 0.46-0.90, P = .01[randomized OR 0.31, 95% CI 0.17-0.57, P < .001; nonrandomized OR 0.88, 95% CI 0.59-1.31, P = .54]) were observed with multivessel PCI. CONCLUSION Overall, staged multivessel PCI improved short- and long-term survival and reduced repeat PCI. Still, large randomized trials are required to confirm the benefits of staged multivessel PCI in STEMI.
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Kelly DJ, McCann GP, Blackman D, Curzen NP, Dalby M, Greenwood JP, Fairbrother K, Shipley L, Kelion A, Heatherington S, Khan JN, Nazir S, Alahmar A, Flather M, Swanton H, Schofield P, Gunning M, Hall R, Gershlick AH. Complete Versus culprit-Lesion only PRimary PCI Trial (CVLPRIT): a multicentre trial testing management strategies when multivessel disease is detected at the time of primary PCI: rationale and design. EUROINTERVENTION 2013; 8:1190-8. [PMID: 23425543 DOI: 10.4244/eijv8i10a183] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Primary percutaneous coronary intervention (PPCI) is the preferred strategy for acute ST-segment elevation myocardial infarction (STEMI), with evidence of improved clinical outcomes compared to fibrinolytic therapy. However, there is no consensus on how best to manage multivessel coronary disease detected at the time of PPCI, with little robust data on best management of angiographically significant stenoses detected in non-infarct-related (N-IRA) coronary arteries. CVLPRIT will determine the optimal management of N-IRA lesions detected during PPCI. METHODS AND RESULTS CVLPRIT (Complete Versus culprit-Lesion only PRimary PCI Trial) is an open-label, prospective, randomised, multicentre trial. STEMI patients undergo verbal "assent" on presentation. Patients are included when angiographic MVD has been detected, and randomised to culprit (IRA)-only PCI (n=150) or in-patient complete multivessel PCI (n=150). Cumulative major adverse cardiac events (MACE) - all-cause mortality, recurrent MI, heart failure, need for revascularisation (PCI or CABG) will be recorded at 12 months. Secondary endpoints include safety endpoints of confirmed ischaemic stroke, intracranial haemorrhage, major non-intracranial bleeding, and repair of vascular complications. A cardiac magnetic resonance (CMR) substudy will provide mechanistic data on infarct size, myocardial salvage index and microvascular obstruction. A cost efficacy analysis will be undertaken. CONCLUSIONS The management of multivessel coronary artery disease in the setting of PPCI for STEMI, including the timing of when to perform non-culprit-artery revascularisation if undertaken, remains unresolved. CVLPRIT will yield mechanistic insights into the myocardial consequence of N-IRA intervention undertaken during the peri-infarct period.
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Affiliation(s)
- Damian J Kelly
- Department of Cardiology, University Hospitals of Leicester, Leicester, United Kingdom
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Biondi Zoccai G, Abbate A, D'Ascenzo F, Presutti D, Peruzzi M, Cavarretta E, Marullo AGM, Lotrionte M, Frati G. Percutaneous coronary intervention in nonagenarians: pros and cons. J Geriatr Cardiol 2013; 10:82-90. [PMID: 23610578 PMCID: PMC3627716 DOI: 10.3969/j.issn.1671-5411.2013.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Revised: 01/15/2013] [Accepted: 02/28/2013] [Indexed: 02/05/2023] Open
Abstract
Percutaneous coronary intervention is a mainstay in the management of symptomatic or high-risk coronary artery disease. The bulk of clinical evidence and experience underlying this fact relies, however, on relatively young patients. Indeed, few data of very limited quality are available which adequately define the risk-benefit and cost-benefit profile of coronary angioplasty and stenting in very old subjects, such as those of 90 years of age or older (i.e., nonagenarians). The aim of this review is to provide a concise, yet practical, synthesis of the available evidence on percutaneous coronary revascularization in the very elderly. The main arguments elaborated upon are to what extent we can extrapolate findings from studies including younger patients to nonagenarians, whether we should provide higher priority to prognosis or quality of life in such patients, and whether we can afford to allocate vast resources to care for such subjects in an era of financial constraints. Our review of 18 studies and 1082 patients suggest that percutaneous coronary intervention is feasible and associated with acceptable short- and long-term results in this population, which is nonetheless fraught with a high mortality risk irrespective of the revascularization procedure. Accordingly, the pros and cons of percutaneous coronary intervention should be carefully weighed when considering this treatment in nonagenarians.
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Affiliation(s)
- Giuseppe Biondi Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, 04100 Latina, Italy
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O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX, Anderson JL, Jacobs AK, Halperin JL, Albert NM, Brindis RG, Creager MA, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Kushner FG, Ohman EM, Stevenson WG, Yancy CW. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2012; 127:e362-425. [PMID: 23247304 DOI: 10.1161/cir.0b013e3182742cf6] [Citation(s) in RCA: 1071] [Impact Index Per Article: 89.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2012; 61:e78-e140. [PMID: 23256914 DOI: 10.1016/j.jacc.2012.11.019] [Citation(s) in RCA: 2191] [Impact Index Per Article: 182.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Multivessel Versus Culprit-Only Revascularization: One Time Versus Staged Procedures for the ACS Population. Curr Cardiol Rep 2012; 14:528-36. [DOI: 10.1007/s11886-012-0272-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Meliga E, Fiorina C, Valgimigli M, Belli R, Gagnor A, Sheiban I, Resmini C, Tizzani E, Aranzulla T, Scrocca I, DE Benedictis M, Conte MR. Early angio-guided complete revascularization versus culprit vessel PCI followed by ischemia-guided staged PCI in STEMI patients with multivessel disease. J Interv Cardiol 2011; 24:535-41. [PMID: 22010970 DOI: 10.1111/j.1540-8183.2011.00666.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Optimal management of multivessel disease (MVD) in ST-segment elevation myocardial infarction (STEMI) patients treated by primary percutaneous coronary intervention (PCI) is still unclear. OBJECTIVES To compare short- and long-term clinical outcomes of early-staged, angio-guided approach and delayed, ischemia-guided treatment of non-infarct-related arteries (IRAs). METHODS Consecutive patients with STEMI and MVD treated with primary PCI in 6 tertiary care centers were retrospectively selected and analyzed. Major adverse cardiac events (MACE) were defined as the composite end-point of death, MI, and repeat revascularization. All the events were adjudicated according to the Academic Research Consortium (ARC) definitions. RESULTS In the time period 2004-2008, 800 primary PCIs in STEMI patients with MVD were performed. Four hundred and seventeen were addressed to early-staged, angio-guided PCI of non-IRAs (CR group) and 383 to an incomplete revascularization (IncR group). During the hospital stay, no difference in terms of death and repeat revascularization was found between groups but the incidence of periprocedural MI/reinfarction and MACE was significantly higher in the CR group (13.9% vs. 3.1%, P = 0.01 and 14.1% vs. 9.1%, P = 0.017, respectively). At a mean follow-up of 642 ± 545 days, no difference in terms of death and MI was found between the CR and IncR group. The MACE-free survival was significantly higher in the IncR group (73.8% vs. 57%, log rank 0.05), mainly driven by the lower incidence of re-PCI. CONCLUSIONS Early complete revascularization based only on angiographic findings in patients with STEMI and MVD is associated with an excess of periprocedural/re-MI and with a significantly higher incidence of MACE at follow-up.
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Affiliation(s)
- Emanuele Meliga
- Interventional Cardiology Unit, A.O. Ordine Mauriziano Umberto I, Turin, Italy.
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Vlaar PJ, Mahmoud KD, Holmes DR, van Valkenhoef G, Hillege HL, van der Horst ICC, Zijlstra F, de Smet BJGL. Culprit vessel only versus multivessel and staged percutaneous coronary intervention for multivessel disease in patients presenting with ST-segment elevation myocardial infarction: a pairwise and network meta-analysis. J Am Coll Cardiol 2011; 58:692-703. [PMID: 21816304 DOI: 10.1016/j.jacc.2011.03.046] [Citation(s) in RCA: 203] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Revised: 02/28/2011] [Accepted: 03/01/2011] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The purposes of this study were to investigate whether, in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD), percutaneous coronary intervention (PCI) should be confined to the culprit or also nonculprit vessels and, when performing PCI for nonculprit vessels, whether it should take place during primary PCI or staged procedures. BACKGROUND A significant percentage of STEMI patients have MVD. However, the best PCI strategy for nonculprit vessel lesions is unknown. METHODS Pairwise and network meta-analyses were performed on 3 PCI strategies for MVD in STEMI patients: 1) culprit vessel only PCI strategy (culprit PCI), defined as PCI confined to culprit vessel lesions only; 2) multivessel PCI strategy (MV-PCI), defined as PCI of culprit vessel as well as ≥1 nonculprit vessel lesions; and 3) staged PCI strategy (staged PCI), defined as PCI confined to culprit vessel, after which ≥1 nonculprit vessel lesions are treated during staged procedures. Prospective and retrospective studies were included when research subjects were patients with STEMI and MVD undergoing PCI. The primary endpoint was short-term mortality. RESULTS Four prospective and 14 retrospective studies involving 40,280 patients were included. Pairwise meta-analyses demonstrated that staged PCI was associated with lower short- and long-term mortality as compared with culprit PCI and MV-PCI and that MV-PCI was associated with highest mortality rates at both short- and long-term follow-up. In network analyses, staged PCI was also consistently associated with lower mortality. CONCLUSIONS This meta-analysis supports current guidelines discouraging performance of multivessel primary PCI for STEMI. When significant nonculprit vessel lesions are suitable for PCI, they should only be treated during staged procedures.
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Affiliation(s)
- Pieter J Vlaar
- Department of Cardiology, Thorax Center, University Medical Center Groningen, Groningen, The Netherlands.
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Bangalore S, Kumar S, Poddar KL, Ramasamy S, Rha SW, Faxon DP. Meta-analysis of multivessel coronary artery revascularization versus culprit-only revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease. Am J Cardiol 2011; 107:1300-10. [PMID: 21349487 DOI: 10.1016/j.amjcard.2010.12.039] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Revised: 12/31/2010] [Accepted: 12/31/2010] [Indexed: 12/01/2022]
Abstract
American College of Cardiology/American Heart Association guidelines for management of patients with ST-segment elevation myocardial infarction (STEMI) recommend culprit artery-only revascularization (CULPRIT) based on safety concerns during noninfarct-related artery intervention. However, the data to support this safety concern are scant. Searches were performed in PubMed/EMBASE/CENTRAL for studies evaluating multivessel revascularization versus CULPRIT in patients with STEMI and multivessel disease (MVD). A multivessel revascularization strategy had to be performed at the time of CULPRIT or during the same hospitalization. Early (≤30-day) and long-term outcomes were evaluated. Among 19 studies (23 arms) that evaluated 61,764 subjects with STEMI and MVD, multivessel revascularization was performed in a minority of patients (16%). For early outcomes, there was no significant difference for outcomes of mortality, MI, stroke, and target vessel revascularization, with a 44% decrease in risk of repeat percutaneous coronary intervention and major adverse cardiovascular events (odds ratio 0.68, 95% confidence interval 0.57 to 0.81) with multivessel revascularization compared to CULPRIT. Similarly, for long-term outcomes (follow-up 2.0 ± 1.1 years), there was no difference for outcomes of MI, target vessel revascularization, and stent thrombosis, with 33%, 43%, and 53% decreases in risk of mortality, repeat percutaneous coronary intervention, coronary artery bypass grafting, respectively, and major adverse cardiovascular events (odds ratio 0.60, 95% confidence interval 0.50 to 0.72) with multivessel revascularization compared to CULPRIT. In conclusion, in patients with STEMI and MVD, multivessel revascularization appears to be safe compared to culprit artery-only revascularization. These findings support the need for a large-scale randomized trial to evaluate revascularization strategies in patients with STEMI and MVD.
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Affiliation(s)
- Sripal Bangalore
- Department of Medicine, Division of Cardiology, New York University School of Medicine, New York, New York, USA.
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Sethi A, Bahekar A, Bhuriya R, Singh S, Ahmed A, Khosla S. Complete versus culprit only revascularization in acute ST elevation myocardial infarction: A meta-analysis. Catheter Cardiovasc Interv 2011; 77:163-70. [DOI: 10.1002/ccd.22647] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Widimsky P, Holmes DR. How to treat patients with ST-elevation acute myocardial infarction and multi-vessel disease? Eur Heart J 2011; 32:396-403. [PMID: 21118854 PMCID: PMC3038335 DOI: 10.1093/eurheartj/ehq410] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2010] [Revised: 09/18/2010] [Accepted: 10/05/2010] [Indexed: 01/05/2023] Open
Abstract
Over 50% of ST-segment elevation myocardial infarction (STEMI) patients suffer multi-vessel coronary artery disease, which is known to be associated with worse prognosis. Treatment strategies used in clinical practice vary from acute multi-vessel percutaneous coronary intervention (PCI), through staged PCI procedures to a conservative approach with primary PCI of only the infarct-related artery (IRA) and subsequent medical therapy unless recurrent ischaemia occurs. Each approach has advantages and disadvantages. This review paper summarizes the international experience and authors' opinion on this clinically important question. Multi-vessel disease in STEMI is not a single entity and thus the treatment approach should be individualized. However, the following general rules can be proposed till future large randomized trials prove otherwise: (i) Single-vessel acute PCI should be the default strategy (to treat only the IRA during the acute phase of STEMI). (ii) Acute multi-vessel PCI can be justified only in exceptional patients with multiple critical (>90%) and potentially unstable lesions. (iii) Significant lesions of the non-infarct arteries should be treated either medically or by staged revascularization procedures-both options are currently acceptable.
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Affiliation(s)
- Petr Widimsky
- Cardiocenter, Third Faculty of Medicine, Charles University Prague, Hospital Kralovske Vinohrady, Prague 10, Czech Republic.
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Biondi-Zoccai G, Lotrionte M, Sheiban I. Management of multivessel coronary disease after ST-elevation myocardial infarction treated by primary coronary angioplasty. Am Heart J 2010; 160:S28-35. [PMID: 21147289 DOI: 10.1016/j.ahj.2010.10.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Primary percutaneous coronary intervention of the infarct-related artery is now considered the gold standard for patients with acute ST-elevation myocardial infarction. However, a sizable portion of patients with ST-elevation myocardial infarction have concomitant multivessel disease, which raises important therapeutic and prognostic issues. Indeed, it is still unclear whether percutaneous coronary intervention of the culprit vessel alone is superior, equivalent, or inferior in terms of risk-benefit balance in comparison to a strategy of complete revascularization, with percutaneous coronary intervention of nonculprit vessels as well. The present systematic review provides an updated prospective on the rationale, background, and outcomes of culprit-only versus multivessel percutaneous revascularization in subjects undergoing primary percutaneous coronary intervention. Our findings clearly demonstrate that multivessel coronary disease significantly and adversely impacts on patient prognosis, yet a culprit-only revascularization strategy should be sought after in most cases, unless patient instability or symptoms/signs of residual myocardial ischemia support nonculprit vessel intervention.
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van der Schaaf RJ, Claessen BE, Hoebers LP, Verouden NJ, Koolen JJ, Suttorp MJ, Barbato E, Bax M, Strauss BH, Olivecrona GK, Tuseth V, Glogar D, Råmunddal T, Tijssen JG, Piek JJ, Henriques JPS. Rationale and design of EXPLORE: a randomized, prospective, multicenter trial investigating the impact of recanalization of a chronic total occlusion on left ventricular function in patients after primary percutaneous coronary intervention for acute ST-elevation myocardial infarction. Trials 2010; 11:89. [PMID: 20858263 PMCID: PMC2949852 DOI: 10.1186/1745-6215-11-89] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Accepted: 09/21/2010] [Indexed: 01/28/2023] Open
Abstract
Background In the setting of primary percutaneous coronary intervention, patients with a chronic total occlusion in a non-infarct related artery were recently identified as a high-risk subgroup. It is unclear whether ST-elevation myocardial infarction patients with a chronic total occlusion in a non-infarct related artery should undergo additional percutaneous coronary intervention of the chronic total occlusion on top of optimal medical therapy shortly after primary percutaneous coronary intervention. Possible beneficial effects include reduction in adverse left ventricular remodeling and preservation of global left ventricular function and improved clinical outcome during future coronary events. Methods/Design The Evaluating Xience V and left ventricular function in Percutaneous coronary intervention on occLusiOns afteR ST-Elevation myocardial infarction (EXPLORE) trial is a randomized, prospective, multicenter, two-arm trial with blinded evaluation of endpoints. Three hundred patients after primary percutaneous coronary intervention for ST-elevation myocardial infarction with a chronic total occlusion in a non-infarct related artery are randomized to either elective percutaneous coronary intervention of the chronic total occlusion within seven days or standard medical treatment. When assigned to the invasive arm, an everolimus-eluting coronary stent is used. Primary endpoints are left ventricular ejection fraction and left ventricular end-diastolic volume assessed by cardiac Magnetic Resonance Imaging at four months. Clinical follow-up will continue until five years. Discussion The ongoing EXPLORE trial is the first randomized clinical trial powered to investigate whether recanalization of a chronic total occlusion in a non-infarct related artery after primary percutaneous coronary intervention for ST-elevation myocardial infarction results in a better preserved residual left ventricular ejection fraction, reduced end-diastolic volume and enhanced clinical outcome. Trial registration trialregister.nl NTR1108.
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Affiliation(s)
- René J van der Schaaf
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Bangalore S, Faxon DP. Coronary Intervention in Patients With Acute Coronary Syndrome: Does Every Culprit Lesion Require Revascularization? Curr Cardiol Rep 2010; 12:330-7. [DOI: 10.1007/s11886-010-0115-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Culprit Vessel Percutaneous Coronary Intervention Versus Multivessel and Staged Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction Patients With Multivessel Disease. JACC Cardiovasc Interv 2010; 3:22-31. [DOI: 10.1016/j.jcin.2009.10.017] [Citation(s) in RCA: 217] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Revised: 09/04/2009] [Accepted: 10/13/2009] [Indexed: 11/22/2022]
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Chen HC, Tsai TH, Fang HY, Sun CK, Lin YC, Leu S, Chung SY, Chai HT, Yang CH, Hsien YK, Wu CJ, Yip HK. Benefit of Revascularization in Non-Infarct-Related Artery in Multivessel Disease Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. Int Heart J 2010; 51:319-24. [DOI: 10.1536/ihj.51.319] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Huang-Chung Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Tzu-Hsien Tsai
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Hsiu-Yu Fang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Cheuk-Kwan Sun
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Yu-Chun Lin
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Steve Leu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Sheng-Ying Chung
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Han-Tan Chai
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Cheng-Hsu Yang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Yuan-Kai Hsien
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Chiung-Jen Wu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Hon-Kan Yip
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
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Claessen BEPM, van der Schaaf RJ, Verouden NJ, Stegenga NK, Engstrom AE, Sjauw KD, Kikkert WJ, Vis MM, Baan J, Koch KT, de Winter RJ, Tijssen JGP, Piek JJ, Henriques JPS. Evaluation of the Effect of a Concurrent Chronic Total Occlusion on Long-Term Mortality and Left Ventricular Function in Patients After Primary Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2009; 2:1128-34. [PMID: 19926056 DOI: 10.1016/j.jcin.2009.08.024] [Citation(s) in RCA: 173] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2009] [Accepted: 08/06/2009] [Indexed: 01/16/2023]
Affiliation(s)
- Bimmer E P M Claessen
- Department of Cardiology, Academic Medical Center-University of Amsterdam, Amsterdam, the Netherlands
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Varani E, Balducelli M, Aquilina M, Vecchi G, Hussien MN, Frassineti V, Maresta A. Single or multivessel percutaneous coronary intervention in ST-elevation myocardial infarction patients. Catheter Cardiovasc Interv 2008; 72:927-33. [DOI: 10.1002/ccd.21722] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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