Revascularization strategies in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease: urgent or staged?

The impact of incomplete revascularization on early and late outcomes in ST-elevation myocardial infarction

BACKGROUND

In ST-elevation myocardial infarction (STEMI) in patients with multivessel disease, there is a lack of consensus regarding the importance of complete revascularization and the timing of treatment of nonculprit stenoses. Our objective was to investigate the impact of incomplete revascularization in STEMI patients using the residual Synergy Between PCI with TAXUS and Cardiac Surgery score (rSS) to define completeness of revascularization.

METHODS

This study examined associations between incomplete revascularization, determined by the rSS, and the combined outcome of cardiac death and myocardial infarction (MI). Patients were divided into groups: rSS = 0 (complete revascularization), rSS = 1-8 (incomplete revascularization with a low burden of residual disease), or rSS >8 (incomplete revascularization with a high burden of residual disease).

RESULTS

The rSS score was calculated in 589 consecutive patients; 25% had an rSS of 0, 42% rSS 1-8, and 33% rSS >8. At median follow-up of 3.5 years, cardiac death and MI occurred in 5% of rSS = 0 patients, 15% rSS = 1-8, and 26% with rSS >8 (P < .001). The rSS was powerful independent predictor of cardiac death and MI (hazard ratio 5.05, CI 2.89-12.00, rSS >8 vs rSS 0, P < .001 and hazard ratio 2.96, CI 1.31-6.69, rSS = 1-8 vs rSS = 0, P = .009), respectively, and an independent predictor of mortality, MI, unplanned revascularization, and major adverse cardiovascular events.

CONCLUSIONS

In patients with STEMI, the rSS independently predicts cardiac death and MI. Patients with an rSS >8 had substantially higher rates of cardiac death or MI. The rSS can be used to define incomplete revascularization in STEMI and predict adverse outcomes.

ROLE OF SYNTAX SCORE SCALE IN THE STRATIFICATION OF THE NOSOCOMIAL RISK OF CARDIOVASCULAR COMPLICATIONS AND LETHALITY IN PATIENTS WITH ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION

The lethality of patients with acute myocardial infarction with ST-segment elevation (STEMI) depends on many factors. In conditions of timely transportation of the patient to the center of percutaneous coronary intervention one of these factors is the severity of the coronary bed lesion. In clinical practice, the most common method of assessing such lesions is the SYNTAX Score scale.

Aim. To study the impact of the assessment by angiographic SYNTAX Score scale on in-hospital complications and lethality in patients with STEMI.

Material and methods. The single-center observational retrospective study was performed. The medical data of 816 cases of treatment of patients with STEMI in the first 6 hours from the onset of symptoms were analyzed. All patients underwent reperfusion therapy (primary percutaneous coronary intervention or pharmacoinvasive strategy (FIS)) with assessment of the SYNTAX Score index prior to intervention. The main group (SYNTAX Score ≤22 points) and the comparison group (SYNTAX Score index >22 points) were comparable in terms of clinical characteristics and time delays.

Results. An increase in the SYNTAX Score more than 22 points was an independent predictor of hospital complications and lethality (4.9% for SYNTAX Score ≤22 points and 21.9% – for >22 points). The group with a high SYNTAX index was older, had a higher proportion of smokers (46.8% vs 36.1%, p=0.015) and patients with myocardial infarction history (38.5% vs 20.6%, p<0.001), fewer patients to whom the FIS was applied (33.3% vs 45.7%; p=0.017). Nevertheless, in multivariate analysis, the initial clinical data of patients influenced the hospital prognosis, first of all in patients with SYNTAX Score ≤22 points. The group with a more severe lesion of the coronary bed was represented by patients with frequent development of pulmonary edema, cardiogenic shock and ventricular fibrillation. Cardiac complications in this group of patients were less dependent on the initial characteristics. Strong SYNTAX Score correlations were found with left ventricular ejection fraction (r=-0.156, p<0.001), the number of implanted stents (r=0.226, p<0.001), and with complications and lethality. The frequency of hemorrhagic complications did not depend on the severity of the coronary bed lesion.

Conclusion. The use of the SYNTAX Score scale in clinical practice is scientifically grounded and advisable. Stratification of high-risk patients with STEMI during primary angiography based on the SYNTAX Score scale has a high prognostic value.