Impact of multivessel coronary artery disease and noninfarct-related artery revascularization on outcome of patients with ST-elevation myocardial infarction transferred for primary percutaneous coronary intervention (from the EUROTRANSFER Registry)

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

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

Comparing FFR-Guided Complete Revascularization and Conservative Management for Non-Culprit Lesions in STEMI Patients With Multivessel Disease: A Systematic Review and Meta-Analysis

BACKGROUND

In patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease, the optimal management strategy for non-culprit lesions is a subject of ongoing debate. There has been an increasing use of physiology-guidance to assess the extent of occlusion in non-culprit lesions, and hence the need for stenting. Fractional flow reserve (FFR) is commonly used as a technique. This analysis compares FFR versus conservative management in the management of non-culprit lesions in STEMI patients with multivessel disease.

METHODS

A comprehensive literature search was conducted on databases from inception to May 25, 2024. We conducted a random-effects meta-analysis using RevMan version 5.3.0, employing the Der-Simonian and Laird method to combine the data.

RESULTS

The analysis of five RCTs including 3759 patients revealed a significantly lower incidence of major adverse cardiovascular events (composite of all-cause mortality, non-fatal myocardial infarction and the need for repeat revascularization [PCI or CABG]) in the FFR group compared to the conservative management group (RR = 0.65, 95% CI: 0.44-0.96, p = 0.03). The revascularization rates were significantly lower in the FFR group (RR = 0.53, 95% CI: 0.43-0.66, p < 0.00001). Additionally, unplanned hospitalization leading to urgent repeat revascularization and any cause hospitalization were significantly lower in the FFR group (RR = 0.72, 95% CI: 0.56-0.94, p = 0.01), and (RR = 0.62, 95% CI: 0.46-0.84, p = 0.002), respectively. The FFR group had a higher risk of definite stent thrombosis (RR = 2.26, 95% CI: 1.10-4.64, p = 0.03). No significant differences were observed between the two groups in mortality, hospitalization for heart failure, or myocardial infarction. Similarly, bleeding rates, cerebrovascular accidents (CVAs), and contrast-induced nephropathy (CIN) were comparable between both groups.

CONCLUSION

Our findings support FFR-guided PCI to manage non-culprit lesions in STEMI patients with multivessel disease as it is potentially safe, with comparable rates of bleeding, CVAs and CIN. It also improves clinical outcomes, as well as reduces revascularization and hospitalization rates. The risk of stent thrombosis remains a concern, and hence the decision making for FFR-guided complete revascularization should take into account the complexity/risk of the procedure, as well as the patients' individual co-morbidities and preferences.

Rationale and Design of Dual Antiplatelet Therapy in Patients with Coronary Multi-Vessel Disease (DAPT-MVD): A Multicenter, Randomized, Controlled Trial

BACKGROUND

The optimal duration of dual antiplatelet therapy (DAPT) for patients with coronary multi-vessel disease (MVD) who have received drug-eluting stents (DES) remains unclear.

HYPOTHESIS AND METHODS

The Dual Antiplatelet Therapy in Patients with Coronary Multi-Vessel Disease (DAPT-MVD) study is a multicenter, open-label, randomized controlled trial designed to assess the efficacy and safety of extended DAPT in MVD patients 12 months following DES implantation. We plan to enroll 8250 patients across approximately 100 sites in China. Participants will be randomized in a 1:1 ratio to receive either extended DAPT (75 mg clopidogrel plus 75-150 mg aspirin daily) or monotherapy (75-150 mg aspirin daily) beyond 12 months post-DES implantation. The follow-up period will last at least 12 months, with all potential endpoints adjudicated by a blinded Clinical Events Committee. The primary endpoint is major adverse cardiovascular and cerebrovascular events (MACCE), including cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke.

RESULTS

As of April 2024, a total of 8250 participants have been enrolled in the study. The mean age of the enrolled patients was 60.5 ± 8.8years, with 5753 (69.7%) being men.

CONCLUSIONS

The DAPT-MVD study is the first large-scale trial to evaluate the efficacy and safety of prolonged DAPT with clopidogrel plus aspirin beyond 12 months after DES implantation in MVD patients. The trial will provide novel insights into the optimal duration of DAPT for MVD patients (ClinicalTrials. gov ID: NCT04624854. Registered on 10/27/2020).

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Purpose

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

Methods

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

Findings

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

Implications

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

Association between glycemia and multi-vessel lesion in participants undergoing coronary angiography: a cross-sectional study

Background

This study aims to elucidate the association between glycemia and the occurrence of multi-vessel lesions in participants undergoing coronary angiography.

Methods

We analyzed 2,533 patients with coronary artery disease who underwent coronary angiography. Of these, 1,973 patients, identified by the endpoint of multi-vessel lesions, were examined using univariate and multivariate logistic regression analyses to determine the relationship between glycemia levels and multi-vessel lesion occurrence.

Results

The analysis included 1,973 participants, among whom 474 patients were identified with coronary multi-vessel lesions. Univariate logistic regression analysis demonstrated a positive correlation between glycemia and the occurrence of coronary multi-vessel lesions (OR 1.04; 95% CI 1.01-1.08; p = 0.02). The adjusted model indicated that for each unit increase in glycemia, the risk of developing coronary multi-vessel lesions increased by 4%, showing a significant correlation (p < 0.05). Subgroup analyses revealed that the impact of glycemia on multi-vessel lesions in patients with PCI varied according to gender, age, and smoking status, with the effect being more pronounced in men, older patients, and smokers.

Conclusion

Our findings establish a significant association between glycemia and the incidence of multi-vessel lesions, particularly pronounced in male patients, individuals over 45, and smokers.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparison of myocardial perfusion study and invasive hemodynamic measurement of the significance of non-infarct-related residual stenoses in ST elevation myocardial infarction patients

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.

Comparison of angiographic estimation and invasive hemodynamic measurement of the significance of non-infarct-related residual stenoses in ST-elevation myocardial infarction patients

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.

Comparison of Immediate Versus Staged Complete Revascularisation in Patients Presenting With Acute Coronary Syndrome and Multivessel Disease: A Meta-Analysis of Randomized and Non-randomized Studies

Acute myocardial infarction is a critical medical condition that poses a significant health burden, leading to substantial morbidity. Despite advancements in medical care, managing this condition is challenging for patients and society. The preferred approach appears to be comprehensive multivessel revascularization, yet the optimal timing remains uncertain. This study aims to compare immediate complete revascularisation and stage complete vascularization in patients presenting with acute coronary syndrome (ACS) and multivessel coronary artery disease (MVD). The Preferred Reporting of Systematic Reviews and Meta-analysis (PRISMA) guidelines conducted the present meta-analysis. A comprehensive literature search was conducted using online databases, including PubMed, and EMBASE from 2010 onwards, to identify articles that compared cardiovascular outcomes between patients undergoing immediate and staged complete revascularization. We also searched Google Scholar for additional studies relevant to the present meta-analysis. The primary outcome assessed in this study was major adverse cardiovascular events (MACE). Secondary outcomes included all-cause mortality, cardiovascular mortality, myocardial infarction (MI), and revascularization. A total of 15 studies fulfilled pre-defined eligibility criteria and were included in the final analysis. Our analysis shows that staged revascularization is associated with improved outcomes in patients with ACS and multivessel CAD, including all-cause mortality and cardiovascular mortality, without increasing the risk of major adverse cardiovascular events, myocardial infarction, and the need for unplanned revascularization.

Immediate versus staged complete revascularization in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease: results from a prematurely discontinued randomized multicenter trial

BACKGROUND

We aimed to compare clinical outcomes between immediate and staged complete revascularization in primary percutaneous coronary intervention (PCI) for treating ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD).

METHODS

A total of 248 patients were enrolled in a prospective, randomized, and multicenter registry. Immediate revascularization was defined as one-time PCI of culprit and non-culprit lesions at the initial procedure. Staged revascularization was defined as PCI of non-culprit lesions at a later date (mean, 4.4 days; interquartile range, 1-11.4), following initial culprit revascularization. The end points were major adverse cardiovascular events (MACE; composite of total death, recurrent myocardial infarction, and revascularization), any individual components of MACE, cardiac death, stent thrombosis, and stroke at 12 months.

RESULTS

During a follow-up of 1 year, MACE occurred in 12 patients (11.6%) in the immediate revascularization group and in 8 patients (7.5%) in staged revascularization group (hazard ratio [HR] 1.60, 95% confidence interval [CI] 0.65-3.91). The incidence of total death was numerically higher in the immediate group than in the staged group (9.7% vs 2.8%, HR 3.53, 95% CI 0.97-12.84); There were no significant differences between the 2 groups in risks of any individual component of MACE, cardiac death, stroke, and in-hospital complications, such as need for transfusion, bleeding, acute renal failure, and acute heart failure. This study was prematurely terminated due to halt of production of everolimus-eluting stents (manufactured as PROMUS Element by Boston Scientific, Natick, Massachusetts).

CONCLUSIONS

Due to its limited power, no definite conclusion can be drawn regarding complete revascularization strategy from the present study. Further large randomized clinical trials would be warranted to confirm optimal timing of complete revascularization for patients with STEMI and MVD.

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

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

One-year results from the Assessing MICRO-vascular resistances via IMR to predict outcome in ST-elevation myocardial infarction patients with multivessel disease undergoing primary PCI (AMICRO) trial

BACKGROUND

In ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary angioplasty (PPCI) the index of microcirculatory resistance (IMR) correlates to the extent of myocardial damage and left ventricular (LV) function recovery. Data on the IMR time-course and impact on clinical outcome in STEMI patients with multi-vessel disease (MVD) are scarce.

AIMS

We designed a prospective, multicenter clinical trial to assess the infarct-related artery (IRA)-IMR in STEMI patients with MVD undergoing PPCI and to explore its potential in relationship with outcome and LV remodeling.

METHODS

The study enrolled 242 STEMI patients with MVD. Both fractional flow reserve (FFR) and IMR of the IRA were assessed after successful PPCI. Then, FFR/IMR measurements were repeated in the IRA at a staged angiography, and FFR-guided angioplasty was performed in non-IRA lesions. The primary endpoint was the composite of cardiovascular death, re-infarction, re-hospitalization for heart failure, resuscitation or appropriate ICD shock at 1-year follow-up.

RESULTS

A significant improvement of IRA-IMR values (from 47.9 to 34.2, p < 0.0001) was observed early after PPCI. Staged FFR-guided angioplasty was performed in 102 non-IRA lesions. We failed to find a correlation between IRA-IMR, clinical events and LV remodeling. Notwithstanding, in patients with anterior STEMI an inverse correlation between initial IMR values and LV function at follow-up was observed.

CONCLUSION

After successful PPCI, a significant proportion of patients with STEMI and MVD had coronary microvascular dysfunction as assessed by IMR that recovered early after reperfusion. Higher IMR values predicted lack of improvement of LV function only in anterior STEMI.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov/, identifier [NCT02325973].

Present and future of coronary risk assessment

The search for subclinical atherosclerosis is carried out in several arterial districts using ultrasonography and computed tomography (CT). Coronary calcium assessed by computerized tomography (calcium score) is a well-validated marker of atherosclerosis and able to correlate with the extent of coronary artery disease and the risk of cardiovascular events. The evaluation of carotid atherosclerosis by ultrasonography is a technically simple and low-cost solution. However, the literature does not provide a sufficient number of evidence to clarify the clinical impact of carotid atherosclerosis and in particular the risk of developing cardiac events. According to the researchers of the Progression of Early Subclinical Atherosclerosis (PESA) study, subclinical atherosclerosis research should preferably be carried out in the femoral district, which is more easily affected by atherosclerosis. Pending the data from the PESA study, which will better clarify the role of ultrasound applied in non-coronary districts, the coronary calcifications seems to be a reasonable solution. It is possible that in the future imaging techniques (CT-PET) capable of studying the extent and functional status of coronary atherosclerosis will further improve the identification of the risk of cardiovascular events.

Comparative Effectiveness of Complete Revascularization Strategies in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Disease: A Bayesian Network Meta-Analysis

Whether fractional flow reserve (FFR) should be available for revascularization in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) is controversial. We aimed to compare the efficacy of various complete revascularization (CR) regimens for STEMI patients with MVD. The PubMed and Cochrane Library databases and clinicaltrial.gov were searched for the randomized controlled trials (RCTs) comparing the FFR-guided CR, angiography-guided CR, and culprit-only revascularization (COR) strategies in STEMI patients with MVD. A Bayesian random-effect model was employed to synthesize the evidence in network meta-analysis. We used relative risk (RR) and 95% credible interval (CrI) as measures of effect size. The primary endpoint was the composite outcome of all-cause mortality or myocardial infarction (MI). Twelve RCTs were included. Angiography-guided CR showed a lower event rate of the composite outcome (RR, 0.68; 95%CrI, 0.50–0.87), all-cause mortality (RR, 0.75; 95%CrI, 0.55–0.96), MI (RR, 0.63; 95%CrI, 0.43–0.86), and repeat revascularization (RR, 0.36; 95% CrI, 0.24–0.55) compared with COR. Additionally, angiography-guided CR had a lower risk of primary outcome (RR, 0.64; 95%CrI, 0.38–0.94) and MI (RR, 0.58; 95%CrI, 0.31–0.92) than FFR-guided CR. The difference between the FFR-guided CR and COR in terms of composite outcome, all-cause mortality, and MI was similar. Angiography-guided CR was associated with the highest probability of optimal treatment for the primary outcome (98.5%), followed by FFR-guided CR (1.2%) and COR (0.3%). STEMI patients with MVD benefitted more from angiography-guided CR than from FFR-guided CR. However, only one study compared the effectiveness of FFR-guided and angiography-guided PCI; thus, the comparison between FFR-guided and angiography-guided PCI relied on indirect evidence. Therefore, further studies directly comparing the effectiveness of these two CR strategies are warranted.

Timing of Nonculprit Percutaneous Coronary Intervention after ST-Elevation Myocardial Infarction

INTRODUCTION

Complete revascularization of ST-elevation myocardial infarction (STEMI) patients with multivessel disease (MVD) has recently shown to reduce risk of adverse cardiovascular events, including cardiovascular death. Optimal timing of revascularization of nonculprit lesions remains controversial. We aimed to measure cardiac outcomes related to duration between primary percutaneous coronary intervention (pPCI) of the culprit lesion and staged PCI (sPCI) of nonculprit lesions.

METHODS

From a prospectively collected consecutive registry of 3,002 patients treated for STEMI by pPCI, 1,555 patients with MVD requiring sPCI were identified. Patients were placed into quartiles of duration to sPCI: 0-7 days (Q1), 7-22 days (Q2), 22-42 days (Q3), >42 days (Q4), excluding those who had complete revascularization at the index event. Major adverse cardiac events (MACEs) included all-cause mortality, myocardial infarction, target vessel revascularization, and coronary artery bypass surgery. Cox regression and propensity score matching were performed correcting for confounding factors.

RESULTS

The average age at presentation was 65.7 ± 11.5 years. 333 were female (21.4%). Mean time between pPCI and sPCI was 28.3 days (±24.8). Rates of MACE were Q1 - 16.5%, Q2 - 21.2%, Q3 - 25.8%, and Q4 - 30.1% (log-rank <0.001). Following regression analysis, sPCI remained an independent risk factor for MACE (hazard ratio [HR] = 1.226 [95% confidence interval {CI}: 1.129-1.331, p < 0.001]). There was no association between the time interval up to sPCI with all-cause death (HR = 1.022 [95% CI: 0.925-1.129, p = 0.671]).

CONCLUSIONS

Patients with MVD are at increased risk of experiencing MACE after revascularization of nonculprit vessels with increasing time delay between pPCI and sPCI.

Comparison of Different Timing of Multivessel Intervention During Index-Hospitalization for Patients With Acute Myocardial Infarction

Background: Many patients presenting with acute myocardial infarction (AMI) were found to have a multivessel disease. Uncertainty still exists in the optimal revascularization strategy in AMI patients. The purpose of this study was to assess the outcome of immediate multivessel revascularization compared with staged multivessel percutaneous coronary intervention (PCI) in patients with AMI.

Method: This was a nationwide cohort study of 186,112 patients first diagnosed with AMI, 78,699 of whom received PCI for revascularization. Patients who received repetitive PCI during the index hospitalization were referred to as staged multivessel PCI. Immediate multivessel PCI was defined as patients with two-vessel PCI or three-vessel PCI during the index procedure. Cox proportional hazards regression models were performed to evaluate the different indicators of mortality risks in AMI.

Result: Immediate multivessel PCI was associated with a worse long-term outcome than staged multivessel PCI during the index admission (log-rank P < 0.001). There was a higher incidence of stroke in patients with multivessel PCI during hospitalization. In Cox analysis, immediate multivessel PCI was an independent risk factor for mortality compared to those with staged multivessel PCI, regardless of the type of myocardial infarction.

Conclusion: This study demonstrated that performing immediate multivessel PCI for AMI may lead to worse long-term survival than staged multivessel PCI. Our findings emphasized the importance of PCI timing for non-infarct-related artery stenosis and provided information to supplement current evidence.

Revascularization Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock: Results from the Portuguese Registry on Acute Coronary Syndromes

BACKGROUND

In patients with acute myocardial infarction (MI), cardiogenic shock (CS), and multivessel disease (MVD) questions remain unanswered when it comes to intervention on non-culprit arteries.

OBJECTIVE

This article aims to 1) characterize patients with MI, CS and MVD included in the Portuguese Registry on Acute Coronary Syndromes (ProACS); 2) compare different revascularization strategies in the sample; 3) identify predictors of in-hospital mortality among these patients.

METHODS

Observational retrospective study of patients with MI, CS and MVD included in the ProACS between 2010 and 2018. Two revascularization strategies were compared: complete during the index procedure (group 1); and complete or incomplete during the index hospitalization (groups 2-3). The primary endpoint was a composite of in-hospital death or MI. Statistical significance was defined by a p-value <0.05.

RESULTS

We identified 127 patients with MI, CS, and MVD (18.1% in group 1, and 81.9% in groups 2-3), with a mean age of 7012 years, and 92.9% of the sample being diagnosed with ST-segment elevation MI (STEMI). The primary endpoint occurred in 47.8% of the patients in group 1 and 37.5% in group 2-3 (p = 0.359). The rates of in-hospital death, recurrent MI, stroke, and major bleeding were also similar. The predictors of in-hospital death in this sample were the presence of left ventricle systolic dysfunction on admission (OR 16.8), right bundle branch block (OR 7.6), and anemia (OR 5.2) (p ≤ 0.02 for both).

CONCLUSIONS

Among patients with MI, CS, and MVD included in the ProACS, there was no significant difference between complete and incomplete revascularization during the index hospitalization regarding the occurrence of in-hospital death or MI. (Arq Bras Cardiol. 2021; 116(5):867-876).

Management of Culprit and Non-Culprit Lesions in Acute Coronary Syndrome

Multivessel coronary artery disease, defined by the presence of a significant stenosis (≥50% diameter) in two or more epicardial coronary vessels, usually occurs in more than 50% of patients with ST-segment elevation myocardial infarction. The latest guidelines indicate revascularization of the non-culprit artery with a recommendation of class IIB. However, the management of non-culprit lesions in patients with acute coronary syndrome is still a matter of debate. This article presents the most recent concepts related to the management of culprit and non-culprit coronary lesions, based on advanced imaging approaches, in order to identify high-risk patients and prevent further acute coronary syndromes.

Complete Revascularization Versus Treatment of the Culprit Artery Only in ST Elevation Myocardial Infarction: A Multicenter Registry

BACKGROUND

Data on the management and prognosis of patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease are limited in Brazil, showing that the available revascularization strategies should be investigated.

OBJECTIVE

To assess the outcomes of complete revascularization versus treatment of the culprit artery only in patients with STEMI and multivessel disease.

METHODS

A prospective cohort study was conducted at two medical centers in southern Brazil with a 1-year follow-up after the index procedure. The primary outcome was a composite of cardiac death, reinfarction, or recurrent angina, while the secondary outcome was stroke, nonfatal cardiac arrest, major bleeding, or need for reintervention. The probability of outcomes occurring was compared between the groups using binary logistic regression. A p-value < 0.05 was considered statistically significant.

RESULTS

Eighty-five patients were included. Their mean age was 62±12 years, and 61 (71.8%) were male. Fifty-eight (68.2%) were treated with complete revascularization and 27 (31.8%) with incomplete revascularization. The chance of both the primary and secondary outcomes occurring was significantly greater among patients treated with incomplete revascularization when compared to those treated with complete revascularization (odds ratio [OR] 5.1, 95% confidence interval [CI] 1.6-16.1 vs. OR 5.2, 95% CI 1.2-22.9, respectively), as well as cardiac death (OR 6.4, 95% CI 1.2-35.3).

CONCLUSION

Registry data from two centers in southern Brazil demonstrate that the complete revascularization strategy is associated with a significant reduction in primary and secondary outcomes in a 1-year follow-up when compared to the incomplete revascularization strategy (Arq Bras Cardiol. 2020; 115(2):229-237).

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.

Coronary Microcirculation Downstream Non-Infarct-Related Arteries in the Subacute Phase of Myocardial Infarction: Implications for Physiology-Guided Revascularization

Background

Concerns exist about reliability of pressure‐wire‐guided coronary revascularization of non‐infarct‐related arteries (non‐IRA). We investigated whether physiological assessment of non‐IRA during the subacute phase of myocardial infarction might be flawed by microcirculatory dysfunction.

Methods and Results

We analyzed non‐IRA that underwent fractional flow reserve, coronary flow reserve, and the index of microcirculatory resistance assessment. Microcirculation and hyperemic response were evaluated in 49 acute myocardial infarction patients (59 non‐IRA) and compared with a matched control group of 46 stable angina (SA) patients (59 vessels). Time between acute myocardial infarction to physiological interrogation was 5.9±2.4 days. Fractional flow reserve was similar in both groups (0.79±0.11 in non‐IRA versus 0.80±0.13 in SA vessels, P=0.527). Lower coronary flow reserve values were found in non‐IRA compared with SA vessels (1.77 [1.25–2.76] versus 2.44 [1.63–4.00], P=0.018), primarily driven by an increased baseline flow in non‐IRA (rest mean transit time 0.58 [0.32–0.83] versus 0.65 s [0.39–1.20], P=0.045), whereas the hyperemic flow was similar (hyperemic mean transit time 0.26 [0.20–0.42] versus 0.26 s [0.18–0.35], P=0.873). No differences were found regarding index of microcirculatory resistance (15.6 [10.4–21.8] in non‐IRA versus 16.7 [11.6–23.6] U in SA vessels, P=0.559). During adenosine infusion, the hyperemic response was similar in both groups (non‐IRA versus SA vessels) in terms of the resistive reserve ratio (3.1±2.1 versus 3.7±2.2, P=0.118).

Conclusions

In the subacute phase of myocardial infarction, non‐IRA show an increased baseline flow that may cause abnormal coronary flow reserve despite preserved hyperemic flow. In non‐IRA, microcirculatory resistance and adenosine‐induced hyperemic response are similar to those found in SA patients. From a physiological perspective, these findings support the use of fractional flow reserve to interrogate non‐IRA during the subacute phase of myocardial infarction.

See Editorial Koh and Samady

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

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

2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Guidelines on the Acute Management of ST-Elevation Myocardial Infarction: Focused Update on Regionalization and Reperfusion

Rapid reperfusion of the infarct-related artery is the cornerstone of therapy for the management of acute ST-elevation myocardial infarction (STEMI). Canada's geography presents unique challenges for timely delivery of reperfusion therapy for STEMI patients. The Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology STEMI guideline was developed to provide advice regarding the optimal acute management of STEMI patients irrespective of where they are initially identified: in the field, at a non-percutaneous coronary intervention-capable centre or at a percutaneous coronary intervention-capable centre. We had also planned to evaluate and incorporate sex and gender considerations in the development of our recommendations. Unfortunately, inadequate enrollment of women in randomized trials, lack of publication of main outcomes stratified according to sex, and lack of inclusion of gender as a study variable in the available literature limited the feasibility of such an approach. The Grading Recommendations, Assessment, Development, and Evaluation system was used to develop specific evidence-based recommendations for the early identification of STEMI patients, practical aspects of patient transport, regional reperfusion decision-making, adjunctive prehospital interventions (oxygen, opioids, antiplatelet therapy), and procedural aspects of mechanical reperfusion (access site, thrombectomy, antithrombotic therapy, extent of revascularization). Emphasis is placed on integrating these recommendations as part of an organized regional network of STEMI care and the development of appropriate reperfusion and transportation pathways for any given region. It is anticipated that these guidelines will serve as a practical template to develop systems of care capable of providing optimal treatment for a wide range of STEMI patients.

Staged complete revascularization or culprit-only percutaneous coronary intervention for multivessel coronary artery disease in patients with ST-segment elevation myocardial infarction and diabetes

BACKGROUND

Recently, several randomized trials have noted improved outcomes with staged percutaneous coronary intervention (PCI) of nonculprit vessels in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease. However, it remains unclear whether diabetes status affects the outcomes after different revascularization strategies. This study thus compared the impact of diabetes status on long-term outcomes after staged complete revascularization with that after culprit-only PCI.

METHODS

From January 2006 to December 2015, 371 diabetic patients (staged PCI: 164, culprit-only PCI: 207) and 834 nondiabetic patients (staged PCI: 412, culprit-only PCI: 422) with STEMI and multivessel disease were enrolled. The primary endpoint was 5-year major adverse cardiac and cerebrovascular event (MACCE), defined as a composite of all-cause death, myocardial infarction (MI), stroke or unplanned revascularization.

RESULTS

The rate of the 5-year composite primary endpoint for diabetic patients was close to that for nondiabetic patients (34.5% vs. 33.7%; adjusted hazard ratio [HR] 1.012, 95% confidence interval [CI] 0.815-1.255). In nondiabetic patients, the 5-year risks of MACCE (31.8% vs. 35.5%; adjusted HR 0.638, 95% CI 0.500-0.816), MI (4.6% vs. 9.2%; adjusted HR 0.358, 95% CI 0.200-0.641), unplanned revascularization (19.9% vs. 24.9%; adjusted HR 0.532, 95% CI 0.393-0.720), and the composite of cardiac death, MI or stroke (11.4% vs. 15.2%; adjusted HR 0.621, 95% CI 0.419-0.921) were significantly lower after staged PCI than after culprit-only PCI. In contrast, no significant difference was found between the two groups with respect to MACCE, MI, unplanned revascularization, and the composite of cardiac death, MI or stroke in diabetic patients. Significant interactions were found between diabetes status and revascularization assignment for the composite of cardiac death, MI or stroke (Pinteraction = 0.013), MI (Pinteraction = 0.005), and unplanned revascularization (Pinteraction = 0.013) at 5 years. In addition, the interaction tended to be significant for the primary endpoint of MACCE (Pinteraction = 0.053). Moreover, the results of propensity score-matching analysis were concordant with the overall analysis in both diabetic and nondiabetic population.

CONCLUSIONS

In patients with STEMI and multivessel disease, diabetes is not an independent predictor of adverse cardiovascular events at 5 years. In nondiabetic patients, an approach of staged complete revascularization is superior to culprit-only PCI, whereas the advantage of staged PCI is attenuated in diabetic patients. Trial registration This study was not registered in an open access database.

Long-Term Safety and Efficacy of Staged Percutaneous Coronary Intervention for Patients with ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Disease

The relative benefit of staged percutaneous coronary intervention (PCI) versus culprit-only PCI in patients with ST-segment elevation myocardial infarction and multivessel coronary disease remains disputable. Therefore, we conducted this study to compare the long-term outcomes of staged complete revascularization and culprit-only PCI in this population. A total of 1,205 patients were treated with staged PCI (n = 576) or culprit-only PCI (n = 629) from January 2006 to December 2015 in our center. After propensity-score matching, 415 pairs of patients were identified, and postmatching absolute standardized differences were <10% for all covariates. The primary endpoint was major adverse cardiac and cerebrovascular event (MACCE), defined as a composite of all-cause death, myocardial infarction (MI), stroke, or unplanned revascularization. The mean follow-up duration was 5 years. Overall, staged complete revascularization was associated with lower risks of MACCE, MI, unplanned revascularization, and a composite of cardiac death, MI or stroke compared with culprit-only PCI in both overall population and propensity-matched cohorts. In Cox proportional hazards regression analysis, the strategy of staged PCI was consistently a significant predictor of lower incidences of MACCE, MI, unplanned revascularization and a composite of cardiac death, MI, or stroke. However, there was no difference in the risks of MACCE, MI and unplanned revascularization between the 2 approaches for diabetic patients. In conclusion, among patients with ST-segment elevation myocardial infarction and multivessel disease who underwent primary PCI, an approach of staged complete revascularization is superior to culprit-only PCI at 5-year follow-up. Nevertheless, the advantage of staged PCI is attenuated in diabetic patients.

Metaanalysis of Multivessel vs Culprit Artery Only Percutaneous Coronary Intervention in ST Elevation Myocardial Infarction

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.

Relation of Circulating Trimethylamine N-Oxide With Coronary Atherosclerotic Burden in Patients With ST-segment Elevation Myocardial Infarction

The gut microbial metabolite trimethylamine N-oxide (TMAO) promotes atherosclerosis and cardiovascular diseases. TMAO levels are associated with the coronary atherosclerotic burden in patients with stable coronary artery disease. However, the relation between TMAO levels and the coronary atherosclerotic burden in patients with ST-segment elevation myocardial infarction (STEMI) is unknown. We prospectively enrolled 2 cohorts in this study, including 335 patients with STEMI and 53 healthy controls. The coronary atherosclerotic burden was quantified by the number of diseased coronary arteries and the SYNTAX score. The median TMAO levels in patients with STEMI and healthy controls were 2.18 (interquartile range [IQR]: 1.34 to 3.90) μM and 1.23 [IQR: 0.84 to 2.42] μM, respectively. Of the 335 patients with STEMI, TMAO levels were significantly higher in the multivessel disease group than in the single-vessel disease group (p <0.001) and in the group with intermediate-high SYNTAX scores (SYNTAX score ≥23) than in the group with low SYNTAX scores (SYNTAX score ≤22; p <0.001). Based on the ordinal logistic regression analysis adjusted for traditional risk factors, elevated TMAO levels predicted both a high SYNTAX score (adjusted odds ratio [OR]: 1.16; 95% confidence interval [CI] 1.06 to 1.29; p = 0.001) and the presence of multivessel disease (adjusted OR: 1.15; 95% CI 1.01 to 1.32; p = 0.035). In conclusion, plasma TMAO levels are associated with a high coronary atherosclerotic burden in patients with STEMI.

Long-term outcomes of in-hospital staged revascularization versus culprit-only intervention for patients with ST-segment elevation myocardial infarction and multivessel disease

BACKGROUND

The long-term relative benefit of culprit-only percutaneous coronary intervention (PCI) and staged PCI in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease remains disputable. This study aimed to compare the long-term outcomes of culprit-only PCI and in-hospital staged complete revascularization in real-world patients with STEMI and multivessel coronary artery disease.

PATIENTS AND METHODS

A total of 452 patients were treated with in-hospital staged complete revascularization (n=133) or culprit-only PCI (n=319) between May 2012 and December 2015 in our center. The primary end point was major adverse cardiac and cerebrovascular event (MACCE), defined as a composite of all-cause death, nonfatal myocardial infarction, stroke, and unplanned revascularization.

RESULTS

The median follow-up period was 3.2 years. Overall, treatment with in-hospital staged complete revascularization can reduce the incidence of the primary end point of MACCE in both the overall population [hazard ratio (HR): 0.48; 95% confidence interval (CI): 0.29-0.82] and the propensity-matched cohorts (HR: 0.51; 95% CI: 0.27-0.97). After correction of the possible confounders, staged PCI remained associated with decreased risk of MACCE (HR: 0.56; 95% CI: 0.33-0.96). Besides, the strategy of staged PCI tended to be associated with lower risk of a composite of cardiac death, myocardial infarction, and stroke than culprit-only PCI in multivariable-adjusted analysis (HR: 0.30; 95% CI: 0.09-1.01).

CONCLUSION

In patients with STEMI and multivessel disease undergoing primary PCI, an approach of in-hospital staged complete revascularization was associated with a better 3-year composite outcome compared with culprit-only PCI.

Value of gated-SPECT MPI for ischemia-guided PCI of non-culprit vessels in STEMI patients with multivessel disease after primary PCI

There remains a clinical question of which patients benefit from revascularization of non-culprit coronary artery stenosis in the setting of acute ST-segment elevation myocardial infraction (STEMI). This is a large population of patients with prior studies showing 40 to 70% of patients with STEMI having non-culprit stenosis. This article reviews the current state of the literature evaluating outcomes of those previously randomized to revascularization of non-culprit stenosis around the time of the STEMI. We propose a new study design to utilize gated-SPECT in the decision process by using an ischemic burden of > 5% as a cut-off for revascularization vs. complete revascularization without ischemia assessment.

Fractional Flow Reserve-Guided Strategy in Acute Coronary Syndrome. A Systematic Review and Meta-Analysis

Background

There are limited data on the prognosis of deferral of lesion treatment in patients with acute coronary syndrome (ACS) based on fractional flow reserve (FFR).

Objectives

To provide a systematic review of the current evidence on the prognosis of deferred lesions in ACS patients compared with deferred lesions in non-ACS patients, on the basis of FFR.

Methods

We searched Medline, EMBASE, and the Cochrane Library for studies published between January 2000 and September 2017 that compared prognosis of deferred revascularization of lesions on the basis of FFR in ACS patients compared with non-ACS patients. We conducted a pooled relative risk meta-analysis of four primary outcomes: mortality, cardiovascular (CV) mortality, myocardial infarction (MI) and target-vessel revascularization (TVR).

Results

We identified 7 studies that included a total of 5,107 patients. A pooled meta-analysis showed no significant difference in mortality (relative risk [RR] = 1.44; 95% CI, 0.9-2.4), CV mortality (RR = 1.29; 95% CI = 0.4-4.3) and TVR (RR = 1.46; 95% CI = 0.9-2.3) after deferral of revascularization based on FFR between ACS and non-ACS patients. Such deferral was associated with significant additional risk of MI (RR = 1.83; 95% CI = 1.4-2.4) in ACS patients.

Conclusion

The prognostic value of FFR in ACS setting is not as good as in stable patients. The results demonstrate an increased risk of MI but not of mortality, CV mortality, and TVR in ACS patients.

2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: comments from the Dutch ACS working group

On behalf of the Dutch ACS working group, we discuss the most important changes in recommendations in the 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation relevant for both the general and interventional cardiologist.

Gender-Related Particularities in Acute Myocardial Infarction – a Study on a Patient Cohort from North East Romania

Introduction: Cardiovascular disease is the leading cause of death among women irrespective of race or ethnicity, and about half of these deaths are caused by coronary artery disease. Several studies have reported that cardiovascular diseases manifest themself with a delay of about 7–10 years in women and that they have higher in-hospital mortality. It has not yet been established whether female gender itself, through biological and sociocultural differences, represents a risk factor for early in-hospital mortality in ST-segment elevation acute myocardial infarction (STEMI). The aim of our study was to identify the angiographic particularities in women with STEMI from North East Romania.

Material and Methods: For one year, 207 (31.7%) women and 445 (68.3%) men diagnosed with acute myocardial infarction were hospitalized in the Cardiology Clinic of the “Prof. Dr. George I. M. Georgescu” Institute of Cardiovascular Diseases in Iași, Romania.

Results: The highest incidence of symptom onset was between 6:00 a.m. and 12:00 a.m., this morning polarization being more obvious in women. Within the first two hours of admission to the hospital, coronary angiography was performed in 78.1% of men and only 67.3% of women, the difference being statistically significant (p <0.05). We found that a large number of women had multivascular coronary disease (47.9% vs. 42.3%). At the same time, we found that left main disease and multivascular disease were more frequent in women than in men (3.8% vs. 0.7%, p = 0.001 for left main plus two-vessel disease, and 19.4% vs. 14.8%, p = 0.0005 for three-vessel disease).

Conclusions: In women, coronary events began more frequently in the morning, with atypical symptoms; also, fewer women presented to the hospital within the first 12 hours after the onset of the acute event. Compared to men, women from North East Romania present a higher incidence of multivascular atherosclerotic coronary lessions, indicating a higher severity of STEMI in the female population from this geographical area.

Identification of candidates for coronary artery bypass grafting admitted with STEMI and Multivessel Disease

BACKGROUND

The optimal management of patients with multivessel coronary artery disease (MVD) admitted with STEMI is under debate. CABG is rarely performed, even on ideal candidates. A provisional PCI without stent implantation may allow complete surgical revascularization (CSR) in a subset of patient that we sought to identify in this study.

METHODS

Patients with STEMI from April 2014 to October 2016 were evaluated and those with a TIMI flow <3 in the culprit vessel, and an additional stenosis of >70% in an epicardial vessel or sidebranch >2.5 mm were selected. Epidemiological variables, surgical risk scores and SYNTAX and SYNTAX II scores were analyzed. All the selected patients were discussed in a post hoc heart-team, and predictors of 12-month events were also analyzed.

RESULTS

Seventy-two (19.0%) accomplished MVD criteria. Mean SYNTAX was 19 ± 13 points and SYNTAX II score recommended CABG in 12 patients (16.7%) and heart-team discussion in 60 (83.3%). All patients were discussed in a post hoc heart-team, which concluded that 21 (29.2%) patients could have been good candidates for CSR. After one year follow-up, SYNTAX II PCI > 40 was found to be the sole independent predictor for 12-month events (OR 12.9 [2.7-62.1], p = 0.001).

CONCLUSIONS

MVD and STEMI with a SYNTAX II PCI > 40 should be discussed in an ad-hoc heart team, after a provisional revascularization of the culprit vessel, and should be considered for CSR, especially when the RCA is the culprit artery and there is a complex disease in the left coronary artery.

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.

Gender-Specific Differences in All-Cause Mortality Between Incomplete and Complete Revascularization in Patients With ST-Elevation Myocardial Infarction and Multi-Vessel Coronary Artery Disease

The best revascularization strategy (complete vs incomplete revascularization) in patients with ST-elevation myocardial infarction (STEMI) is still debated. The interaction between gender and revascularization strategy in patients with STEMI on all-cause mortality is uncertain. The aim of the present study was to evaluate gender-specific difference in all-cause mortality between incomplete and complete revascularization in patients with STEMI and multi-vessel coronary artery disease. The study population consisted of 375 men and 115 women with a first STEMI and multi-vessel coronary artery disease without cardiogenic shock at admission or left main stenosis. The 30-day and 5-year all-cause mortality was examined in patients categorized according to gender and revascularization strategy (incomplete and complete revascularization). Within the first 30 days, men and women with incomplete revascularization were associated with higher mortality rates compared with men with complete revascularization. However, the gender-strategy interaction variable was not independently associated with 30-day mortality after STEMI when corrected for baseline characteristics and angiographic features. Within the survivors of the first 30 days, men with incomplete revascularization (compared with men with complete revascularization) were independently associated with all-cause mortality during 5 years of follow-up (hazard ratios 3.07, 95% confidence interval 1.24;7.61, p = 0.016). In contrast, women with incomplete revascularization were not independently associated with 5-year all-cause mortality (hazard ratios 0.60, 95% confidence interval 0.14;2.51, p = 0.48). In conclusion, no gender-strategy differences occurred in all-cause mortality within 30 days after STEMI. However, in the survivors of the first 30 days, incomplete revascularization in men was independently associated with all-cause mortality during 5-year follow-up, but this was not the case in women.

Predicting risk of cardiac events among ST-segment elevation myocardial infarction patients with conservatively managed non-infarct-related artery coronary artery disease: An analysis of the Duke Databank for Cardiovascular Disease

BACKGROUND

Recent randomized evidence has demonstrated benefit with complete revascularization during the index hospitalization for multivessel coronary artery disease ST-segment elevation myocardial infarction (STEMI) patients; however, this benefit likely depends on the risk of future major adverse cardiovascular events (MACE).

METHODS

Using data from Duke University Medical Center (2003-2012), we identified those at high risk for 1-year MACE among 664 STEMI patients with conservatively managed non-infarct-related artery (non-IRA) lesions. Using multivariable logistic regression, we identified clinical and angiographic characteristics associated with MACE (death, myocardial infarction, urgent revascularization) to 1 year and developed an integer-based risk prediction model for clinical use.

RESULTS

In this cohort (median age 60 years, 30% female), the unadjusted Kaplan-Meier rates for MACE at 30 days and 1 year were 10% and 28%, respectively. Characteristics associated with MACE at 1 year included reduced left ventricular ejection fraction, hypertension, heart failure, higher-risk non-IRA vessels (left main), renal insufficiency, and greater % stenosis of non-IRA lesions. A 15-point risk score including these variables had modest discrimination (C-index 0.67) across a spectrum of subsequent risk (4%-88%) for 1-year MACE.

CONCLUSIONS

There is a wide spectrum of risk following primary percutaneous coronary intervention for STEMI patients with multivessel disease. Using readily available clinical characteristics, the expected incidence of MACE by 1 year can be calculated with a simplified risk score, facilitating a tailored approach to clinical care.