Effect of residual myocardial ischemia on recovery of left ventricular function after primary percutaneous coronary intervention

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).

Comprehensive Review of Complete Versus Culprit-only Revascularization for Multivessel Disease in ST-segment Elevation Myocardial Infarction

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Complete or Incomplete Revascularization for ST-Segment Elevation Myocardial Infarction: The PRAMI Trial to COMPLETE

Many patients presenting with ST-segment elevation myocardial infarction (STEMI) have multivessel coronary artery disease (CAD). Following successful primary percutaneous coronary intervention (PCI) of culprit lesion, whether to routinely revascularize nonculprit lesions or treat them medically has been debated. Recently, the large-scale, multinational COMPLETE trial definitively established benefit of routine, staged, angiographically guided nonculprit lesion PCI in reducing hard clinical outcomes, including the composite of death from cardiovascular causes or new myocardial infarction, with no major safety concerns. A strategy of complete revascularization with routine nonculprit lesion PCI in suitable lesions should be standard of care in STEMI with multivessel CAD.

Complete Versus Culprit-Only Revascularization in STEMI: a Contemporary Review

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.

Successful revascularization of noninfarct related artery with chronic total occlusion among acute myocardial infarction patients: A systematic review and meta-analysis

BACKGROUND

Randomized trials and meta-analyses demonstrated that chronic total occlusion (CTO) in noninfarct related artery (n-IRA) was associated with increased all-cause mortality. Recently, several observational studies suggested that the successful revascularization of n-IRA with CTO decreased all-cause mortality.

METHODS

A systematic search was performed in Cochrane Controlled Trials Registry, PubMed, MEDLINE, and EMBASE databases for relevant studies. Article assessing the prognostic role of revascularization of n-IRA with CTO was enrolled in this meta-analysis. Data and characteristics of each study were extracted. A meta-analysis was performed to generate pooled odds ratio (OR) and 95% confidence intervals (95% CIs) for outcomes. The primary outcome was major adverse cardiac events (MACE). Beg funnel plot was used to evaluate publication bias.

RESULTS

Four observational studies and one randomized controlled trial involving 1083 patients were enrolled for analysis. Compared with nonreperfusion, the successful percutaneous coronary intervention (PCI) of n-IRA with CTO was related to decreased all-cause mortality (OR was 0.34, and 95% CI was 0.2-0.59; P = .0001).

CONCLUSIONS

Successful PCI of n-IRA with CTO could significantly decrease all-cause mortality, cardiac mortality, MACE, and stroke in acute myocardial infarction patients. In addition, it was not associated with the increased risk of repeat revascularization and myocardial infarction.

Staged versus One-Time Complete Revascularization with Percutaneous Coronary Intervention in STEMI Patients with Multivessel Disease: A Systematic Review and Meta-Analysis

Introduction

In patients with acute ST-elevation myocardial infarction (STEMI), the preferred intervention is percutaneous coronary intervention (PCI).Whether staged PCI (S-PCI) or one-time complete PCI (MV-PCI) is more beneficial and safer in terms of treating the non-culprit vessel during the primary PCI procedure is unclear. We performed a meta-analysis of all randomized and non-randomized controlled trials comparing S-PCI with MV-PCI in patients with acute STEMI and MVD.

Methods

Studies of STEMI with multivessel disease receiving primary PCI were searched in PUBMED, EMBASE and The Cochrane Register of Controlled Trials from January 2004 to December 2014. The primary end points were long-term rates of major adverse cardiovascular events and their components—mortality, reinfarction, and target-vessel revascularization. Data were combined using a fixed-effects model.

Results

Of 507 citations, 10 studies (4 randomized, 6 nonrandomized; 820 patients, 562 staged PCI and 347 one-time, complete multi-vessel PCI) were included. S-PCI compared to MV-PCI significantly reduced mortality both long-term (OR 0.44, 95% CI 0.29–0.66, P<0.0001, I² = 0%) and short-term (OR 0.23, 95% CI 0.1–0.51, P = 0.0003, I² = 0%). There was a trend toward reduced risk of MACE with s-PCI compared with MV-PCI (OR 0.83, 0.62–1.12, P = 0.22, I2 = 0%). No difference between S-PCI and MV-PCI was observed in reinfarction (OR 0.97, 0.61–1.55, P = 0.91, I² = 0%), or target vessel revascularization (OR1.17, 95% CI 0.81–1.69, P = 0.40, I² = 8%).

Conclusions

The staged strategy for non-culprit lesions improved short- and long-term survival and should remain the standard approach to primary PCI in patients with STEMI; one-time complete multivessel PCI may be associated with greater mortality risk. However, additional large, randomized trials are required to confirm the optimal timing of a staged procedure on the non-culprit vessel in STEMI.

Complete versus culprit-only revascularization in ST-elevation myocardial infarction and multivessel disease

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.

Managing Multivessel Coronary Artery Disease in Patients With ST-Elevation Myocardial Infarction: A Comprehensive Review

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.

Meta-Analysis of Randomized Controlled Trials Comparing Multivessel Versus Culprit-Only Revascularization for Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Disease Undergoing Primary Percutaneous Coronary Intervention

Current guidelines recommend against revascularization of the noninfarct artery during the index percutaneous coronary intervention (PCI) in hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI). This was based largely on observational studies with few data coming from randomized controlled trials (RCTs). Recently, several small-to-moderate sized RCTs have provided data, suggesting that a multivessel revascularization approach may be appropriate. We performed a meta-analysis of RCTs comparing multivessel percutaneous coronary intervention (MV PCI) versus culprit vessel-only revascularization (COR) during primary PCI in patients with STEMI and multivessel coronary disease (MVCD). We searched Medline, PubMed, and Scopus databases for RCTs comparing MV PCI versus COR in patients with STEMI and MVCD. The incidence of all-cause death, cardiac death, recurrent myocardial infarction, and revascularization during follow-up were extracted. Four RCTs fit our primary selection criteria. Among these, 566 patients underwent MV PCI (either at the time of the primary PCI or as a staged procedure) and 478 patients underwent COR. During long-term follow-up (range 1 to 2.5 years), combined data indicated a significant reduction in all-cause mortality (relative risk [RR] 0.57, 95% confidence interval [CI] 0.36 to 0.92, p = 0.02) and in cardiac death (RR 0.38, 95% CI 0.20 to 0.73, p = 0.004) with MV PCI. In addition, there was a significantly lower risk of recurrent myocardial infarction (RR 0.41, 95% CI 0.23 to 0.75; p = 0.004) and future revascularization (RR 0.37, 95% CI 0.27 to 0.52; p <0.00001). In conclusion, from the RCT data, MV PCI appears to improve outcomes in patients with STEMI and MVCD.

Multi-vessel versus culprit-vessel and staged percutaneous coronary intervention in STEMI patients with multivessel disease: a meta-analysis of randomized controlled trials

INTRODUCTION

Percutaneous coronary intervention (PCI) is preferred in patients with acute ST-elevation myocardial infarction (STEMI). In patients with acute STEMI with multivessel disease (MVD), the guidelines recommend culprit vessel PCI (CV-PCI) in the absence of hemodynamic instability. We performed a meta-analysis of all randomized controlled trials (RCTs) comparing multi-vessel PCI (MV-PCI) with CV-PCI or staged PCI (S-PCI) in patients with acute STEMI and MVD.

METHODS

PubMed, EMBASE and CENTRAL were searched for publications since inception to December 2013. Random effects model was used to compute summary effects.

RESULTS

Four RCTs (840 patients) were identified. MV-PCI compared to CV-PCI significantly reduced the risks of major adverse cardiac events (MACE)-a composite of MI, revascularization and all-cause mortality (RR: 0.46, 95% CI: 0.35-0.60, P<0.00001) by reducing the risks of MI (0.35, 0.17-0.71, P=0.004) and revascularization (0.35, 0.24-0.52, P<0.00001). The risk of all-cause mortality was not different (0.69, 0.39-1.21, P=0.19). S-PCI and MV-PCI had similar risks of MACE (0.96, 0.59-1.57, P=0.87), MI (0.60, 0.20-1.78, P=0.36), revascularization (0.86, 0.47-1.54, P=0.60) and all-cause mortality (1.50, 0.44-5.07, P=0.57).

CONCLUSIONS

MV-PCI compared to CV-PCI resulted in lower risks of MACE driven by lower MI and revascularization in patients with STEMI and multi-vessel disease.

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

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.