1
|
Chen L, Zhong J, Hong R, Chen Y, Li B, Wang L, Yan Y, Chen L, Chen Q, Luo Y. Predictive value of the inconsistency between the residual and post-PCI QFR for prognosis in PCI patients. Front Cardiovasc Med 2024; 11:1297218. [PMID: 38694566 PMCID: PMC11062415 DOI: 10.3389/fcvm.2024.1297218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 03/22/2024] [Indexed: 05/04/2024] Open
Abstract
Introduction To investigate the prognostic value of the consistency between the residual quantitative flow ratio (QFR) and postpercutaneous coronary intervention (PCI) QFR in patients undergoing revascularization. Methods This was a single-center, retrospective, observational study. All enrolled patients were divided into five groups according to the ΔQFR (defined as the value of the post-PCI QFR minus the residual QFR): (1) Overanticipated group; (2) Slightly overanticipated group; (3) Consistent group; (4) Slightly underanticipated group; and (5) Underanticipated group. The primary outcome was the 5-year target vessel failure (TVF). Results A total of 1373 patients were included in the final analysis. The pre-PCI QFR and post-PCI QFR were significantly different among the five groups. TVF within 5 years occurred in 189 patients in all the groups. The incidence of TVF was significantly greater in the underanticipated group than in the consistent group (P = 0.008), whereas no significant differences were found when comparing the underanticipated group with the other three groups. Restricted cubic spline regression analysis showed that the risk of TVF was nonlinearly related to the ΔQFR. A multivariate Cox regression model revealed that a ΔQFR≤ -0.1 was an independent risk factor for TVF. Conclusions The consistency between the residual QFR and post-PCI QFR may be associated with the long-term prognosis of patients. Patients whose post-PCI QFR is significantly lower than the residual QFR may be at greater risk of TVF. An aggressive PCI strategy for lesions is anticipated to have less functional benefit and may not result in a better clinical outcome.
Collapse
Affiliation(s)
- Lihua Chen
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Heart Medical Center, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Changle District People's Hospital Cardiovascular Department, Fuzhou, Fujian, China
| | - Jiaxin Zhong
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Heart Medical Center, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Ruijin Hong
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Heart Medical Center, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Yuxiang Chen
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Heart Medical Center, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Beilei Li
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Heart Medical Center, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Laicheng Wang
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Heart Medical Center, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Yuanming Yan
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Heart Medical Center, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Lianglong Chen
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Heart Medical Center, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Qin Chen
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Heart Medical Center, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Yukun Luo
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Heart Medical Center, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| |
Collapse
|
2
|
Tindale A, Cretu I, Meng H, Panoulas V. Complete revascularization is associated with higher mortality in patients with ST-elevation myocardial infarction, multi-vessel disease and shock defined by hyperlactataemia: results from the Harefield Shock Registry incorporating explainable machine learning. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:615-623. [PMID: 37309061 PMCID: PMC10519804 DOI: 10.1093/ehjacc/zuad062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/22/2023] [Accepted: 06/07/2023] [Indexed: 06/14/2023]
Abstract
AIMS Revascularization strategy for patients with ST-elevation myocardial infarction (STEMI) and multi-vessel disease varies according to the patient's cardiogenic shock status, but assessing shock acutely can be difficult. This article examines the link between cardiogenic shock defined solely by a lactate of ≥2 mmol/L and mortality from complete vs. culprit-only revascularization in this cohort. METHODS AND RESULTS Patients presenting with STEMI, multi-vessel disease without severe left main stem stenosis and a lactate ≥2 mmol/L between 2011 and 2021 were included. The primary endpoint was mortality at 30 days by revascularization strategy for shocked patients. Secondary endpoints were mortality at 1 year and over a median follow-up of 30 months. Four hundred and eight patients presented in shock. Mortality in the shock cohort was 27.5% at 30 days. Complete revascularization (CR) was associated with higher mortality at 30 days [odds ratio (OR) 2.1 (1.02-4.2), P = 0.043], 1 year [OR 2.4 (1.2-4.9), P = 0.01], and over 30 months follow-up [hazard ratio (HR) 2.2 (1.4-3.4), P < 0.001] compared with culprit lesion-only percutaneous coronary intervention (CLOP). Mortality was again higher in the CR group after propensity matching (P = 0.018) and inverse probability treatment weighting [HR 2.0 (1.3-3.0), P = 0.001]. Furthermore, explainable machine learning demonstrated that CR was behind only blood gas parameters and creatinine levels in importance for predicting 30-day mortality. CONCLUSION In patients presenting with STEMI and multi-vessel disease in shock defined solely by a lactate of ≥2 mmol/L, CR is associated with higher mortality than CLOP.
Collapse
Affiliation(s)
- Alexander Tindale
- Department of Cardiology, Harefield Hospital, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, Hill End Road, Harefield, UB9 6JH, UK
- National Heart and Lung Institute, Imperial College London, Harefield Hospital, Hill End Road, UB9 6JH, London, UK
| | - Ioana Cretu
- College of Engineering, Design and Physical Sciences, Brunel University London, Kingston Lane, Uxbridge, UB8 3PH, UK
| | - Hongying Meng
- College of Engineering, Design and Physical Sciences, Brunel University London, Kingston Lane, Uxbridge, UB8 3PH, UK
| | - Vasileios Panoulas
- Department of Cardiology, Harefield Hospital, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, Hill End Road, Harefield, UB9 6JH, UK
- National Heart and Lung Institute, Imperial College London, Harefield Hospital, Hill End Road, UB9 6JH, London, UK
| |
Collapse
|
3
|
Takura T, Komuro I, Ono M. Trends in the cost-effectiveness level of percutaneous coronary intervention: Macro socioeconomic analysis and health technology assessment. J Cardiol 2023; 81:356-363. [PMID: 36182005 DOI: 10.1016/j.jjcc.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 09/15/2022] [Indexed: 01/09/2023]
Abstract
Percutaneous coronary intervention (PCI), one of the most prevalent techniques of revascularization, is a procedure that remarkably improves treatment outcomes. However, it consumes large amounts of medical resources and has resulted in an increased socioeconomic burden due to the increasing number of target patients. In recent years, there have been sporadic discussions, both in Japan and other countries, regarding the optimization of interventions and the perspective of medical economics. Based on this, previous studies on PCI-related cost-effectiveness were reviewed in order to consider the current level of medical economics regarding PCI. Using the databases MEDLINE and EMBASE, a survey involving data from original articles and systematic reviews was conducted from January 2010 to August 2022. Conditions were not imposed on the evidence level due to the paucity of studies, although field studies were prioritized over simulation studies. The macro medical economics of acute myocardial infarction treatment, which is the primary target of PCI, were generally at an average level when compared to those in other countries; however, there is room for further improvement in Japan's performance. Revascularization in a population with multivessel coronary artery disease showed that coronary artery bypass graft surgery tended to be more cost-effective than PCI in the long-term setting. However, it was suggested that PCI may be more cost-effective in patients with SYNTAX Score ≤22 or left main artery disease. A cost-effectiveness report for stable angina patients was not in favor of PCI over medical therapy. Moreover, there were some reports showing the medical economic superiority of early myocardial ischemia evaluation, and it was foreseen that active selection of patients will contribute to the improvement of the overall cost-effectiveness of PCI. In order to further improve the socioeconomic significance of PCI in the future, it is necessary to aim for harmony between clinical practice and health economics.
Collapse
Affiliation(s)
- Tomoyuki Takura
- Department of Healthcare Economics and Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, University of Tokyo Hospital, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
4
|
Akbari T, Al-Lamee R. Percutaneous coronary intervention in multi-vessel disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 44:80-91. [DOI: 10.1016/j.carrev.2022.06.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 01/09/2023]
|
5
|
Wald DS, Hadyanto S, Bestwick JP. Should fractional flow reserve follow angiographic visual inspection to guide preventive percutaneous coronary intervention in ST-elevation myocardial infarction? EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2020; 6:186-192. [DOI: 10.1093/ehjqcco/qcaa012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 01/27/2020] [Accepted: 02/03/2020] [Indexed: 01/02/2023]
Abstract
Abstract
Aims
We aimed to quantify the effect of preventive percutaneous coronary intervention (PCI to non-infarct arteries) on cardiac death and non-fatal myocardial infarction (MI) in patients with ST-elevation myocardial infarction (STEMI) according to whether the decision to carry out preventive PCI was based on angiographic visual inspection (AVI alone) or AVI plus fractional flow reserve (FFR) if AVI showed significant stenosis (AVI plus FFR).
Methods and results
Randomized trials comparing preventive PCI with no preventive PCI in STEMI without shock were identified by a systematic literature search and categorized according to whether they used AVI alone or AVI plus FFR to select patients for preventive PCI. Random effects meta-analyses and tests of heterogeneity were used to compare the two categories in respect of cardiac death and MI as a combined outcome and individually. Eleven eligible trials were identified. For cardiac death and MI, the relative risk estimates for AVI alone vs. AVI plus FFR were 0.39 (0.25–0.61) and 0.85 (0.57–1.28), respectively (P = 0.01 for difference), for cardiac death, alone the estimates were 0.36 (0.19–0.71) and 0.79 (0.36–1.77), respectively (P = 0.15 for difference), and for MI alone, 0.41 (0.23–0.73) and 0.98 (0.62–1.56), respectively (P = 0.04 for difference).
Conclusion
In preventive PCI among STEMI patients, AVI alone achieves a ∼60% reduction in cardiac death and MI but selecting patients using FFR in AVI positive patients loses much of the benefit. Angiographic visual inspection is best used without FFR in this group of patients.
Collapse
Affiliation(s)
- David S Wald
- Wolfson Institute of Preventive Medicine, Queen Mary University of London Charterhouse Square, London EC1M6BQ, UK
| | - Steven Hadyanto
- Wolfson Institute of Preventive Medicine, Queen Mary University of London Charterhouse Square, London EC1M6BQ, UK
| | - Jonathan P Bestwick
- Wolfson Institute of Preventive Medicine, Queen Mary University of London Charterhouse Square, London EC1M6BQ, UK
| |
Collapse
|
6
|
Kim YH, Her AY, Jeong MH, Kim BK, Hong SJ, Kim S, Ahn CM, Kim JS, Ko YG, Choi D, Hong MK, Jang Y. Culprit-only versus multivessel or complete versus incomplete revascularization in patients with non-ST-segment elevation myocardial infarction and multivessel disease who underwent successful percutaneous coronary intervention using newer-generation drug-eluting stents. Atherosclerosis 2020; 301:54-64. [PMID: 32330691 DOI: 10.1016/j.atherosclerosis.2020.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/26/2020] [Accepted: 04/01/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND AIMS The long-term comparative results between culprit-only percutaneous coronary intervention (C-PCI) and multivessel PCI (M-PCI) or those between complete revascularization (CR) and incomplete revascularization (IR) in patients with non-ST-elevation myocardial infarction (NSTEMI) and multivessel disease (MVD) after successful newer-generation drug-eluting stent (DES) implantation are limited. Therefore, we compared the 2-year clinical outcomes in such patients. METHODS A total of 4588 patients with NSTEMI and MVD (C-PCI, n = 2055; M-PCI, n = 2533; CR, n = 2029; IR, n = 504) were evaluated. The primary outcome was major adverse cardiac events (MACEs) defined as all-cause death, recurrent myocardial infarction MI, and any repeat coronary revascularization. The secondary outcome was stent thrombosis (ST). RESULTS The cumulative incidences of the primary and secondary outcomes were similar in the three comparison groups (C-PCI vs. M-PCI, CR vs. IR, or CR vs. C-PCI). However, the cumulative incidence of non-target vessel revascularization (non-TVR) was higher in the C-PCI group than in the M-PCI group (adjusted hazard ratio [aHR]: 2.011; 95% confidence interval [CI]: 1.942-3.985; p = 0.012), higher in the IR group than in the CR group (aHR: 2.051; 95% CI: 1.216-4.183; p = 0.043), and higher in the C-PCI group than in the CR group (aHR: 2.099; 95% CI: 1.237-3.564; p = 0.006). CONCLUSIONS Regarding the higher cumulative incidence of non-TVR, M-PCI and CR were preferred compared to C-PCI or IR in patients with NSTEMI and MVD. However, further randomized studies are required to confirm these findings.
Collapse
Affiliation(s)
- Yong Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Republic of Korea.
| | - Ae-Young Her
- Division of Cardiology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Republic of Korea
| | - Myung Ho Jeong
- Department of Cardiology, Cardiovascular Center, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Byeong-Keuk Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Sung-Jin Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Seunghwan Kim
- Division of Cardiology, Inje University College of Medicine, Haeundae Paik Hospital, Busan, Republic of Korea
| | - Chul-Min Ahn
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Jung-Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Young-Guk Ko
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Donghoon Choi
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Myeong-Ki Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Yangsoo Jang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| |
Collapse
|
7
|
Gershlick AH, Price MJ. Full Revascularization in the Patient With ST-Segment Elevation Myocardial Infarction: The Story So Far. J Am Coll Cardiol 2019; 74:2724-2727. [PMID: 31779787 DOI: 10.1016/j.jacc.2019.10.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 10/22/2019] [Indexed: 01/17/2023]
Affiliation(s)
- Anthony H Gershlick
- Department of Cardiovascular Sciences, University Hospitals of Leicester, Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom.
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California
| |
Collapse
|
8
|
Gershlick AH, Banning AS, Parker E, Wang D, Budgeon CA, Kelly DJ, Kane PO, Dalby M, Hetherington SL, McCann GP, Greenwood JP, Curzen N. Long-Term Follow-Up of Complete Versus Lesion-Only Revascularization in STEMI and Multivessel Disease. J Am Coll Cardiol 2019; 74:3083-3094. [DOI: 10.1016/j.jacc.2019.10.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/01/2019] [Accepted: 10/06/2019] [Indexed: 10/25/2022]
|
9
|
Siebert VR, Borgaonkar S, Jia X, Nguyen HL, Birnbaum Y, Lakkis NM, Alam M. Meta-analysis Comparing Multivessel Versus Culprit Coronary Arterial Revascularization for Patients With Non-ST-Segment Elevation Acute Coronary Syndromes. Am J Cardiol 2019; 124:1501-1511. [PMID: 31575424 DOI: 10.1016/j.amjcard.2019.07.071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/30/2019] [Accepted: 07/31/2019] [Indexed: 11/19/2022]
Abstract
We present a systematic review and meta-analysis comparing efficacy and safety outcomes between single procedure multivessel revascularization (MVR) and culprit vessel only revascularization in patients presenting with non-ST-segment-elevation acute coronary syndrome (NSTE-ACS). NSTE-ACS is the most common form of acute coronary syndrome (ACS), and multivessel disease is common. There is no consensus on the most efficacious single procedure revascularization strategy for patients undergoing percutaneous coronary intervention not meeting coronary artery bypass grafting criteria. Studies in PubMed and EMBASE databases were systematically reviewed, and 15 studies met criteria for inclusion in the meta-analysis. Baseline characteristics between the groups were similar. A random effects model was used to calculate odds ratios (OR) with 95% confidence intervals (CI). Heterogeneity of studies was assessed using Cochrane's Q and Higgins I2 tests. For short-term outcomes, patients who underwent MVR had higher rates of major adverse cardiac events (OR 1.14; 95% CI 1.01 to 1.29; p = 0.03); and stroke (OR 1.94; 95% CI 1.01 to 3.72; p = 0.05), but lower rates of urgent or emergent coronary artery bypass grafting (OR 0.35; 95% CI 0.29 to 0.43; p <0.00001). In the long-term, MVR patients had less frequent major adverse cardiac events (OR 0.76; 95% CI 0.61-0.93; p = 0.009), all-cause death (OR 0.83; 95% CI 0.71 to 0.97; p = 0.03), and repeat revascularization, (OR 0.62; 95% CI 0.42 to 0.90; p = 0.01). MVR following NSTE-ACS was associated with higher short-term risk, but long-term benefit. In conclusion, these results support the use of single procedure multivessel revascularization for NSTE-ACS patients who are suitable candidates at the time of percutaneous coronary intervention.
Collapse
Affiliation(s)
| | - Sanket Borgaonkar
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Xiaoming Jia
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Hong Loan Nguyen
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Yochai Birnbaum
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Nasser M Lakkis
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Mahboob Alam
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| |
Collapse
|
10
|
Complete Revascularization During Primary Percutaneous Coronary Intervention Reduces Death and Myocardial Infarction in Patients With Multivessel Disease: Meta-Analysis and Meta-Regression of Randomized Trials. JACC Cardiovasc Interv 2019; 11:833-843. [PMID: 29747913 DOI: 10.1016/j.jcin.2018.02.028] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 02/16/2018] [Accepted: 02/17/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVES The aim of this study was to compare complete revascularization with a culprit-only strategy in patients presenting with ST-segment elevation myocardial infarction (MI) and multivessel disease by a meta-analysis of randomized trials. BACKGROUND Although several trials have compared complete with culprit-only revascularization in ST-segment elevation MI, it remains unclear whether complete revascularization may lead to improvement in hard endpoints (death and MI). METHODS Randomized trials comparing complete revascularization with culprit-only revascularization in patients with ST-segment elevation MI without cardiogenic shock were identified by a systematic search of published research. Random-effects meta-analysis was performed, comparing clinical outcomes in the 2 groups. RESULTS Eleven trials were identified, including a total of 3,561 patients. Compared with a culprit-only strategy, complete revascularization significantly reduced risk for death or MI (relative risk [RR]: 0.76; 95% confidence interval [CI]: 0.58 to 0.99; p = 0.04). Meta-regression showed that performing complete revascularization at the time of primary percutaneous coronary intervention (PCI) was associated with better outcomes (p = 0.016). The 6 trials performing complete revascularization during primary PCI (immediate revascularization) were associated with a significant reduction in risk for both total mortality (RR: 0.62; 95% CI: 0.39 to 0.97; p = 0.03) and MI (RR: 0.40; 95% CI: 0.25 to 0.66; p < 0.001), whereas the 5 trials performing only staged revascularization did not show any significant benefit in either total mortality (RR: 1.02; 95% CI: 0.65 to 1.62; p = 0.87) or MI (RR: 1.04; 95% CI: 0.48 to 1.68; p = 0.86). CONCLUSIONS When feasible, complete revascularization with PCI can significantly reduce the combined endpoint of death and MI. Complete revascularization performed during primary PCI was also associated with significant reductions in both total mortality and MI, whereas staged revascularization did not improve these outcomes.
Collapse
|
11
|
Rathod KS, Koganti S, Jain AK, Astroulakis Z, Lim P, Rakhit R, Kalra SS, Dalby MC, O'Mahony C, Malik IS, Knight CJ, Mathur A, Redwood S, Sirker A, MacCarthy PA, Smith EJ, Wragg A, Jones DA. Complete Versus Culprit-Only Lesion Intervention in Patients With Acute Coronary Syndromes. J Am Coll Cardiol 2019; 72:1989-1999. [PMID: 30336821 DOI: 10.1016/j.jacc.2018.07.089] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 06/29/2018] [Accepted: 07/30/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND A large proportion of patients presenting with non-ST-segment elevation myocardial infarction (NSTEMI) present with multivessel disease (MVD). There is uncertainty in the role of complete coronary revascularization in this group of patients. OBJECTIVES The aim of this study was to investigate the outcomes of complete revascularization compared with culprit vessel-only intervention in a large contemporary cohort of patients undergoing percutaneous coronary intervention (PCI) for NSTEMI. METHODS The authors undertook an observational cohort study of 37,491 NSTEMI patients treated between 2005 and 2015 at the 8 heart attack centers in London. Clinical details were recorded at the time of the procedure into local databases using the British Cardiac Intervention Society (BCIS) PCI dataset. A total of 21,857 patients (58.3%) presented with NSTEMI and MVD. Primary outcome was all-cause mortality at a median follow-up of 4.1 years (interquartile range: 2.2 to 5.8 years). RESULTS A total of 11,737 (53.7%) patients underwent single-stage complete revascularization during PCI for NSTEMI, rates that significantly increased during the study period (p = 0.006). Those patients undergoing complete revascularization were older and more likely to be male, diabetic, have renal disease and a history of previous myocardial infarction/revascularization compared with the culprit-only revascularization group. Although crude, in-hospital major adverse cardiac event rates were similar (5.2% vs. 4.8%; p = 0.462) between the 2 groups. Kaplan-Meier analysis demonstrated significant differences in mortality rates between the 2 groups (22.5% complete revascularization vs. 25.9% culprit vessel intervention; p = 0.0005) during the follow-up period. After multivariate Cox analysis (hazard ratio: 0.90; 95% confidence interval: 0.85 to 0.97) and the use of propensity matching (hazard ratio: 0.89; 95% confidence interval: 0.76 to 0.98) complete revascularization was associated with reduced mortality. CONCLUSIONS In NSTEMI patients with MVD, despite higher initial (in-hospital) mortality rates, single-stage complete coronary revascularization appears to be superior to culprit-only vessel PCI in terms of long-term mortality rates. This supports the need for further randomized study to confirm these findings.
Collapse
Affiliation(s)
| | | | - Ajay K Jain
- Barts Health NHS Trust, London, United Kingdom
| | - Zoe Astroulakis
- St. George's Healthcare NHS Foundation Trust, St. George's Hospital, London, United Kingdom
| | - Pitt Lim
- St. George's Healthcare NHS Foundation Trust, St. George's Hospital, London, United Kingdom
| | - Roby Rakhit
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | | | - Miles C Dalby
- Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, Middlesex, London, United Kingdom
| | | | - Iqbal S Malik
- Imperial College Healthcare NHS Foundation Trust, Hammersmith Hospital, London, United Kingdom
| | | | | | - Simon Redwood
- St. Thomas' NHS Foundation Trust, Guys & St. Thomas Hospital, London, United Kingdom
| | | | - Philip A MacCarthy
- Kings College Hospital, King's College Hospital NHS Foundation Trust, Denmark Hill, London, United Kingdom
| | | | | | | |
Collapse
|
12
|
Harris JM, Brierley RC, Pufulete M, Bucciarelli-Ducci C, Stokes EA, Greenwood JP, Dorman SH, Anderson RA, Rogers CA, Wordsworth S, Berry S, Reeves BC. A national registry to assess the value of cardiovascular magnetic resonance imaging after primary percutaneous coronary intervention pathway activation: a feasibility cohort study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Cardiovascular magnetic resonance (CMR) is increasingly used in patients who activate the primary percutaneous coronary intervention (PPCI) pathway to assess heart function. It is uncertain whether having CMR influences patient management or the risk of major adverse cardiovascular events in these patients.
Objective
To determine whether or not it is feasible to set up a national registry, linking routinely collected data from hospital information systems (HISs), to investigate the role of CMR in patients who activate the PPCI pathway.
Design
A feasibility prospective cohort study.
Setting
Four 24/7 PPCI hospitals in England and Wales (two with and two without a dedicated CMR facility).
Participants
Patients who activated the PPCI pathway and underwent an emergency coronary angiogram.
Interventions
CMR either performed or not performed within 10 weeks of the index event.
Main outcome measures
A. Feasibility parameters – (1) patient consent implemented at all hospitals, (2) data extracted from more than one HIS and successfully linked for > 90% of consented patients at all four hospitals, (3) HIS data successfully linked with Hospital Episode Statistics (HES) and Patient Episode Database Wales (PEDW) for > 90% of consented patients at all four hospitals and (4) CMR requested and carried out for ≥ 10% of patients activating the PPCI pathway in CMR hospitals. B. Key drivers of cost-effectiveness for CMR (identified from simple cost-effectiveness models) in patients with (1) multivessel disease and (2) unobstructed coronary arteries. C. A change in clinical management arising from having CMR (defined using formal consensus and identified using HES follow-up data in the 12 months after the index event).
Results
A. (1) Consent was implemented (for all hospitals, consent rates were 59–74%) and 1670 participants were recruited. (2) Data submission was variable – clinical data available for ≥ 82% of patients across all hospitals, biochemistry and echocardiography (ECHO) data available for ≥ 98%, 34% and 87% of patients in three hospitals and medications data available for 97% of patients in one hospital. (3) HIS data were linked with hospital episode data for 99% of all consented patients. (4) At the two CMR hospitals, 14% and 20% of patients received CMR. B. In both (1) multivessel disease and (2) unobstructed coronary arteries, the difference in quality-adjusted life-years (QALYs) between CMR and no CMR [‘current’ comparator, stress ECHO and standard ECHO, respectively] was very small [0.0012, 95% confidence interval (CI) –0.0076 to 0.0093 and 0.0005, 95% CI –0.0050 to 0.0077, respectively]. The diagnostic accuracy of the ischaemia tests was the key driver of cost-effectiveness in sensitivity analyses for both patient subgroups. C. There was consensus that CMR leads to clinically important changes in management in five patient subgroups. Some changes in management were successfully identified in hospital episode data (e.g. new diagnoses/procedures, frequency of outpatient episodes related to cardiac events), others were not (e.g. changes in medications, new diagnostic tests).
Conclusions
A national registry is not currently feasible. Patients were consented successfully but conventional consent could not be implemented nationally. Linking HIS and hospital episode data was feasible but HIS data were not uniformly available. It is feasible to identify some, but not all, changes in management in the five patient subgroups using hospital episode data. The delay in obtaining hospital episode data influenced the relevance of some of our study objectives.
Future work
To test the feasibility of conducting the study using national data sets (e.g. HES, British Cardiovascular Intervention Society audit database, Diagnostic Imaging Dataset, Clinical Practice Research Datalink).
Funding
The National Institute for Health Research (NIHR) Health Services and Delivery Research programme. This study was designed and delivered in collaboration with the Clinical Trials and Evaluation Unit, a UK Clinical Research Collaboration-registered clinical trials unit that, as part of the Bristol Trials Centre, is in receipt of NIHR clinical trials unit support funding.
Collapse
Affiliation(s)
- Jessica M Harris
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Rachel C Brierley
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Maria Pufulete
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Chiara Bucciarelli-Ducci
- National Institute for Health Research (NIHR) Bristol Cardiovascular Research Unit, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Elizabeth A Stokes
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - John P Greenwood
- Multidisciplinary Cardiovascular Research Centre and Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Stephen H Dorman
- National Institute for Health Research (NIHR) Bristol Cardiovascular Research Unit, Bristol Heart Institute, University of Bristol, Bristol, UK
| | | | - Chris A Rogers
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sunita Berry
- NHS England, South West Clinical Networks and Senate, Bristol, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| |
Collapse
|
13
|
Angiography-guided Multivessel Percutaneous Coronary Intervention Versus Ischemia-guided Percutaneous Coronary Intervention Versus Medical Therapy in the Management of Significant Disease in Non-Infarct-related Arteries in ST-Elevation Myocardial Infarction Patients With Multivessel Coronary Disease. Crit Pathw Cardiol 2019; 17:77-82. [PMID: 29768315 DOI: 10.1097/hpc.0000000000000144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND In ST-elevation myocardial infarction (STEMI) patients with multivessel (MV) disease, after primary percutaneous coronary intervention (PCI), emerging evidence suggests that significant disease in non-infarct-related coronary arteries (IRAs) should be routinely stented. Whether this procedure should be guided by angiography alone or ischemia testing is unclear. METHODS All STEMI patients treated with primary PCI between January 1, 2005, and December 31, 2012, at a tertiary cardiology center were reviewed retrospectively. Inclusion criterion is patients with at least 70% stenosis in non-IRAs. There were 3 treatment groups: (1) angiography-guided MV-PCI, (2) ischemia-guided PCI, and (3) medical therapy. Primary endpoint is all-cause mortality, and secondary end point is major adverse cardiovascular events (MACE), including death, acute coronary syndrome, revascularization, or stent thrombosis. Event-free survivals were compared using multivariate Cox proportional-hazards analysis. A propensity score-adjusted analysis was performed. RESULTS Four hundred forty-seven STEMI patients had >70% stenosis in non-IRAs. For all-cause mortality, the 3 strategies did not differ. For MACE, ischemia-guided PCI was associated with the lowest MACE rate, followed by angiography-guided PCI and medical therapy, which was associated with the highest MACE rate, driven by death and myocardial infarction. Hazard ratios (HRs) for MACE: angiography-guided MV-PCI versus ischemia-guided MV-PCI: HR = 2.23 [95% confidence interval (CI), 1.11-4.48; P = 0.023]; medical therapy versus angiography-guided MV-PCI: HR = 1.58 (95% CI, 0.99-2.63; P = 0.062); medical therapy versus ischemia-guided MV-PCI: HR = 1.72 (95% CI, 1.08-2.74; P = 0.022). Propensity score-adjusted analysis yielded similar results. CONCLUSIONS After primary PCI, complete revascularization in STEMI multivessel disease is associated with lower MACE rates than medical therapy. However, ischemia-testing-guided rather than angiography-guided revascularization was associated with the lowest MACE. This study provides preliminary data and hypotheses for future randomized controlled studies.
Collapse
|
14
|
Sakamoto K, Matoba T, Mohri M, Ueki Y, Tsujita Y, Yamasaki M, Tanaka N, Hokama Y, Fukutomi M, Hashiba K, Fukuhara R, Suwa S, Matsuura H, Tachibana E, Yonemoto N, Nagao K. Clinical characteristics and prognostic factors in acute coronary syndrome patients complicated with cardiogenic shock in Japan: analysis from the Japanese Circulation Society Cardiovascular Shock Registry. Heart Vessels 2019; 34:1241-1249. [PMID: 30715570 DOI: 10.1007/s00380-019-01354-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 01/25/2019] [Indexed: 12/22/2022]
Abstract
Cardiogenic shock frequently leads to death even with intensive treatment. Although the leading cause of cardiogenic shock is acute coronary syndrome (ACS), the clinical characteristics and the prognosis of ACS with cardiogenic shock in the present era still remain to be elucidated. We analyzed clinical characteristics and predictors of 30-day mortality in ACS with cardiogenic shock in Japan. The Japanese Circulation Society Cardiovascular Shock registry was a prospective, observational, multicenter, cohort study. Between May 2012 and June 2014, 495 ACS patients with cardiogenic shock were analyzed. The primary endpoint was 30-day all-cause mortality. The median [interquartile range; IQR] age was 71.0 [63.0, 80.0] years. The median [IQR] value of systolic blood pressure (SBP) and heart rate were 75.0 [50.0, 86.5] mm Hg and 65.0 [38.0, 98.0] bpm, respectively. Multivariable analysis showed an odds ratio (OR) of 4.76 (confidence intervals; CI 1.97-11.5, p < 0.001) in the lowest SBP category (< 50 mm Hg) for SBP ≥ 90 mm Hg. Moreover, age per 10 years increase (OR 1.38, CI 1.18-1.61, p = 0.002), deep coma (OR 3.49, CI 1.94-6.34, p < 0.001), congestive heart failure (OR 3.81, CI 2.04-7.59, p < 0.001) and left main trunk disease (LMTD) (OR 2.81, CI 1.55-5.10, p < 0.001) were independent predictors. Severe hypotension, older age, deep coma, congestive heart failure, and LMTD were independent unfavorable factors in ACS complicated by cardiogenic shock in Japan. A prompt assessment of high-risk patients referring to those predictors in emergency room could lead to appropriate treatment without delay.
Collapse
Affiliation(s)
- Kazuo Sakamoto
- JCS Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiovascular Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Tetsuya Matoba
- JCS Shock Registry Scientific Committee, Tokyo, Japan. .,Department of Cardiovascular Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Masahiro Mohri
- JCS Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiology, Japan Community Healthcare Organization Kyushu Hospital, Kitakyushu, Japan
| | - Yasushi Ueki
- JCS Shock Registry Scientific Committee, Tokyo, Japan.,Emergency and Critical Care Center, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yasuyuki Tsujita
- JCS Shock Registry Scientific Committee, Tokyo, Japan.,Department of Critical and Intensive Care Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Masao Yamasaki
- JCS Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiovascular Medicine, NTT Medical Center, Tokyo, Japan
| | - Nobuhiro Tanaka
- JCS Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Yohei Hokama
- JCS Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Motoki Fukutomi
- JCS Shock Registry Scientific Committee, Tokyo, Japan.,Division of Cardiovascular Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan
| | - Katsutaka Hashiba
- JCS Shock Registry Scientific Committee, Tokyo, Japan.,Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Rei Fukuhara
- JCS Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Satoru Suwa
- JCS Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiovascular Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Hirohide Matsuura
- JCS Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiology, Miyazaki Medical Association Hospital, Miyazaki, Japan
| | - Eizo Tachibana
- JCS Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiology, Kawaguchi Municipal Medical Center, Kawaguchi, Japan
| | - Naohiro Yonemoto
- JCS Shock Registry Scientific Committee, Tokyo, Japan.,Department of Biostatistics, Kyoto University School of Public Health, Kyoto, Japan
| | - Ken Nagao
- JCS Shock Registry Scientific Committee, Tokyo, Japan.,Cardiovascular Center, Nihon University Hospital, Tokyo, Japan
| |
Collapse
|
15
|
Optimal reperfusion strategy in patients with acute STEMI and multivessel disease-an updated meta-analysis. Herz 2018; 45:272-279. [PMID: 29951946 DOI: 10.1007/s00059-018-4722-2] [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: 03/15/2018] [Revised: 05/12/2018] [Accepted: 06/03/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND This meta-analysis compared the efficacy and safety of culprit-only revascularization (COR) and complete revascularization (CR) in the treatment of patients with acute ST-elevation myocardial infarction (STEMI) and multivessel disease to determine the optimal reperfusion strategy. METHOD We analyzed published multicenter randomized controlled trials to compare COR and CR in patients with acute STEMI and multivessel disease. The PubMed, Cochrane Library, and Ovid databases were searched, and the meta-analysis was performed using Review Manager 5.3 software. RESULTS Eight multicenter randomized controlled trials were selected involving 2870 patients, of whom 1604 underwent COR and 1266 underwent CR. No significant heterogeneity was identified across these selected studies. The CR strategy significantly decreased the incidence of major adverse cardiac events (MACE; odds ratio [OR]: 2.44, 95% CI [95% confidence interval]: 1.96-3.03, p < 0.001), mortality (OR: 1.76, 95% CI: 1.25-2.47, p = 0.001), myocardial infarction (MI, OR: 1.62, 95% CI: 1.12-2.35, p = 0.01), and repeat revascularization (OR: 3.20, 95% CI: 2.41-4.24, p < 0.001) compared with the COR approach. Moreover, no significant difference was identified in the safety indexes, including contrast-induced nephropathy, stroke, and bleeding, between the CR and the COR group (p > 0.05). CONCLUSION The present meta-analysis determined that CR is an efficacious and safe reperfusion strategy in patients with acute STEMI and multivessel disease.
Collapse
|
16
|
Clinical outcomes of complete revascularization using either angiography-guided or fractional flow reserve-guided drug-eluting stent implantation in non-culprit vessels in ST elevation myocardial infarction patients: insights from a study based on a systematic review and meta-analysis. Int J Cardiovasc Imaging 2018; 34:1349-1364. [DOI: 10.1007/s10554-018-1362-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 04/20/2018] [Indexed: 12/31/2022]
|
17
|
Gerber Y, Weston SA, Enriquez-Sarano M, Manemann SM, Chamberlain AM, Jiang R, Roger VL. Atherosclerotic Burden and Heart Failure After Myocardial Infarction. JAMA Cardiol 2018; 1:156-62. [PMID: 27437886 DOI: 10.1001/jamacardio.2016.0074] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
IMPORTANCE Whether the extent of coronary artery disease (CAD) is associated with the occurrence of heart failure (HF) after myocardial infarction (MI) is not known. Furthermore, whether this association might differ by HF type according to preserved or reduced ejection fraction (EF) has yet to be determined. OBJECTIVES To evaluate in a community cohort of patients with incident (first-ever) MI the association of angiographic CAD with subsequent HF and to examine the prognostic role of CAD according to HF subtypes: HF with reduced EF and HF with preserved EF. DESIGN, SETTING, AND PARTICIPANTS A population-based cohort study was conducted in 1922 residents of Olmsted County, Minnesota, with incident MI diagnosed between January 1, 1990, and December 31, 2010, and no prior HF; study participants were followed up through March 31, 2013. The extent of angiographic CAD was determined at baseline and categorized according to the number of major epicardial coronary arteries with 50% or more lumen diameter obstruction. MAIN OUTCOMES AND MEASURES The primary end point was time to incident HF. The primary exposure variable was the extent of CAD as expressed by the number of major coronary arteries with significant obstruction (0-, 1-, 2-, or 3-vessel disease) obtained from coronary angiograms performed no more than 1 day after the MI. Heart failure was ascertained by the Framingham criteria and classified by type according to EF (50% cutoff). RESULTS Of the 1922 participants, 1258 (65.4%) were men (mean [SD] age, 64 [13] years). During a mean follow-up period of 6.7 (5.9) years, 588 patients (30.6%) developed HF. With death and recurrent MI modeled as competing risks, the cumulative incidence rates of post-MI HF among patients with 0 or 1, 2, and 3 diseased vessels were 10.7%, 14.6%, and 23.0% at 30 days; and 14.7%, 20.6%, and 29.8% at 5 years, respectively (P < .001 for trend). After adjustment for clinical characteristics in a Cox proportional hazards regression model, the hazard ratios (95% CIs) for HF were 1.25 (0.99-1.59) and 1.75 (1.40-2.20) in patients with 2 and 3 vessels vs 0 or 1 occluded vessel, respectively (P < .001 for trend). The increased risk with a greater number of occluded vessels was independent of the occurrence of a recurrent MI and did not differ appreciably by HF type. CONCLUSIONS AND RELEVANCE The extent of angiographic CAD is an indicator of post-MI HF regardless of HF type and independent of recurrent MI. These data underscore the need to further investigate the processes taking place in the transition from myocardial injury to HF.
Collapse
Affiliation(s)
- Yariv Gerber
- Division of Cardiovascular Diseases, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota2Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Susan A Weston
- Division of Cardiovascular Diseases, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Maurice Enriquez-Sarano
- Division of Cardiovascular Diseases, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Sheila M Manemann
- Division of Cardiovascular Diseases, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Alanna M Chamberlain
- Division of Cardiovascular Diseases, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Ruoxiang Jiang
- Division of Cardiovascular Diseases, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Véronique L Roger
- Division of Cardiovascular Diseases, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
18
|
Meta-Analysis of Culprit-Only Versus Multivessel Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Disease. Am J Cardiol 2018; 121:529-536. [PMID: 29304995 DOI: 10.1016/j.amjcard.2017.11.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 11/09/2017] [Accepted: 11/13/2017] [Indexed: 01/10/2023]
Abstract
Recently, several randomized controlled trials (RCT) in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) have compared a strategy of routine multivessel percutaneous coronary intervention (PCI) performed either as a single procedure or as staged procedures to culprit-only PCI. All of these trials have been underpowered for clinical end points. We searched PubMed, Embase, and Cochrane Central Register of Controlled Trials for RCT comparing multivessel PCI with culprit-only PCI in patients with STEMI and MVD. The primary efficacy outcome was the composite rate of death or MI. Other efficacy outcomes included death, MI, and repeat revascularization. Safety outcomes were contrast-associated acute kidney injury, stroke, and major bleeding. Pairwise direct comparison and mixed-treatment comparison network meta-analyses were performed. Eleven trials that enrolled 3,150 patients with a total of 5,296 patient-years of follow-up were included. In direct comparison meta-analysis, single-procedure multivessel PCI was associated with a reduction in the risk of death or MI (rate ratio [RR] = 0.52; 95% confidence interval [CI] 0.37 to 0.73; p <0.001), due to less death (RR = 0.64; 95% CI 0.40 to 1.02; p = 0.06) and MI (RR = 0.42; 95% CI 0.25 to 0.69; p <0.0001) compared with culprit-only PCI. No heterogeneity (I2 = 0) was present between studies. In contrast, staged multivessel PCI did not significantly reduce death or MI compared with culprit-only PCI. Both multivessel PCI strategies reduced the risk of repeat revascularization without significant differences in safety outcomes. Results were consistent in the mixed-treatment comparison meta-analysis. In conclusion, the present meta-analysis suggests that single-procedure multivessel PCI may be the preferred strategy in patients with STEMI and MVD.
Collapse
|
19
|
Kwon SW, Park SD, Moon J, Oh PC, Jang HJ, Park HW, Kim TH, Lee K, Suh J, Kang W. Complete Versus Culprit-Only Revascularization for ST-Segment Elevation Myocardial Infarction and Multivessel Disease in the 2 nd Generation Drug-Eluting Stent Era: Data from the INTERSTELLAR Registry. Korean Circ J 2018; 48:989-999. [PMID: 30334385 PMCID: PMC6196156 DOI: 10.4070/kcj.2017.0387] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 04/11/2018] [Accepted: 05/08/2018] [Indexed: 12/03/2022] Open
Abstract
Background and Objectives We aimed to compare outcomes of complete revascularization (CR) versus culprit-only revascularization for ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) in the 2nd generation drug-eluting stent (DES) era. Methods From 2009 to 2014, patients with STEMI and MVD, who underwent primary percutaneous coronary intervention (PCI) using a 2nd generation DES for culprit lesions were enrolled. CR was defined as PCI for a non-infarct-related artery during the index admission. Major adverse cardiovascular event (MACE) was defined as cardiovascular (CV) death, non-fatal myocardial infarction, target lesion revascularization, or heart failure during the follow-up year. Results In total, 705 MVD patients were suitable for the analysis, of whom 286 (41%) underwent culprit-only PCI and 419 (59%) underwent CR during the index admission. The incidence of MACE was 11.5% in the CR group versus 18.5% in the culprit-only group (hazard ratio [HR], 0.56; 95% confidence interval [CI], 0.37–0.86; p<0.01; adjusted HR, 0.64; 95% CI, 0.40–0.99; p=0.04). The CR group revealed a significantly lower incidence of CV death (7.2% vs. 12.9%; HR, 0.51; 95% CI, 0.31–0.86; p=0.01 and adjusted HR, 0.57; 95% CI; 0.32–0.97; p=0.03, respectively). Conclusions CR was associated with better outcomes including reductions in MACE and CV death at 1 year of follow-up compared with culprit-only PCI in the 2nd generation DES era.
Collapse
Affiliation(s)
- Sung Woo Kwon
- Department of Cardiology, Inha University Hospital, Incheon, Korea
| | - Sang Don Park
- Department of Cardiology, Inha University Hospital, Incheon, Korea.
| | - Jeonggeun Moon
- Department of Cardiology, Gachon University Gil Medical Center, Incheon, Korea
| | - Pyung Chun Oh
- Department of Cardiology, Gachon University Gil Medical Center, Incheon, Korea
| | - Ho Jun Jang
- Department of Cardiology, Sejong General Hospital, Bucheon, Korea
| | - Hyun Woo Park
- Department of Cardiology, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Tae Hoon Kim
- Department of Cardiology, Sejong General Hospital, Bucheon, Korea
| | - Kyounghoon Lee
- Department of Cardiology, Gachon University Gil Medical Center, Incheon, Korea
| | - Jon Suh
- Department of Cardiology, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - WoongChol Kang
- Department of Cardiology, Gachon University Gil Medical Center, Incheon, Korea
| |
Collapse
|
20
|
Braga CG, Cid-Alvarez AB, Diéguez AR, Alvarez BA, Otero DL, Sánchez RO, Pena XS, Salvado VG, Trillo-Nouche R, González-Juanatey JR. Prognostic impact of residual SYNTAX score in patients with ST-elevation myocardial infarction and multivessel disease: Analysis of an 8-year all-comers registry. Int J Cardiol 2017; 243:21-26. [DOI: 10.1016/j.ijcard.2017.04.054] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 03/05/2017] [Accepted: 04/10/2017] [Indexed: 11/27/2022]
|
21
|
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.
Collapse
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
| |
Collapse
|
22
|
Patel S, Bailey SR. Revascularization Strategies in STEMI with Multivessel Disease: Deciding on Culprit Versus Complete-Ad Hoc or Staged. Curr Cardiol Rep 2017; 19:93. [PMID: 28840487 DOI: 10.1007/s11886-017-0906-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW This review will address the clinical conundrum of those who may derive clinical benefit from complete revascularization of coronary stenosis that are discovered at the time of ST segment elevation myocardial infarction (STEMI). The decision to revascularize additional vessels with angiographic stenosis beyond the culprit lesion remains controversial, as does the timing of revascularization. RECENT FINDINGS STEMI patients represent a high-risk patient population that have up to a 50% prevalence of multivessel disease. Multivessel disease represents an important risk factor for short- and long-term morbidity and mortality. Potential benefits of multivessel PCI for STEMI might include reduced short- and long-term mortality, revascularization, reduced resource utilization, and costs. Which population will benefit and what the optimal timing of revascularization in the peri-MI period remains controversial. Consideration of multivessel revascularization in the setting of STEMI may occur in up to one half of STEMI patients. Evaluation of the comorbidities including diabetes, extent of myocardium at risk, lesion complexity, ventricular function, and risk factors for complications such as contrast induced nephropathy which is important in determining the appropriate care pathway.
Collapse
Affiliation(s)
- Shalin Patel
- From the Janey Briscoe Center of Excellence for Cardiovascular Research, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78232, USA
| | - Steven R Bailey
- From the Janey Briscoe Center of Excellence for Cardiovascular Research, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78232, USA.
| |
Collapse
|
23
|
Quadri G, D’Ascenzo F, Moretti C, D’Amico M, Raposeiras-Roubín S, Abu-Assi E, Henriques JP, Saucedo J, González-Juanatey JR, Wilton S, Kikkert W, Nuñez-Gil I, Ariza-Sole A, Song X, Alexopoulos D, Liebetrau C, Kawaji T, Huczek Z, Nie SP, Fujii T, Correia L, Kawashiri MA, García-Acuña JM, Southern D, Alfonso E, Terol B, Garay A, Zhang D, Chen Y, Xanthopoulou I, Osman N, Möllmann H, Shiomi H, Omedè P, Montefusco A, Giordana F, Scarano S, Kowara M, Filipiak K, Wang X, Yan Y, Fan JY, Ikari Y, Nakahashi T, Sakata K, Yamagishi M, Kalpak O, Kedev S, Varbella F, Gaita F. Complete or incomplete coronary revascularisation in patients with myocardial infarction and multivessel disease: a propensity score analysis from the “real-life” BleeMACS (Bleeding complications in a Multicenter registry of patients discharged with diagnosis of Acute Coronary Syndrome) registry. EUROINTERVENTION 2017; 13:407-414. [DOI: 10.4244/eij-d-16-00350] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
24
|
Vogel B, Mehta SR, Mehran R. Reperfusion strategies in acute myocardial infarction and multivessel disease. Nat Rev Cardiol 2017; 14:665-678. [DOI: 10.1038/nrcardio.2017.88] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
|
25
|
Pufulete M, Brierley RC, Bucciarelli-Ducci C, Greenwood JP, Dorman S, Anderson RA, Harris J, McAlindon E, Rogers CA, Reeves BC. Formal consensus to identify clinically important changes in management resulting from the use of cardiovascular magnetic resonance (CMR) in patients who activate the primary percutaneous coronary intervention (PPCI) pathway. BMJ Open 2017; 7:e014627. [PMID: 28645959 PMCID: PMC5541580 DOI: 10.1136/bmjopen-2016-014627] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To define important changes in management arising from the use of cardiovascular magnetic resonance (CMR) in patients who activate the primary percutaneous coronary intervention (PPCI) pathway. DESIGN Formal consensus study using literature review and cardiologist expert opinion to formulate consensus statements and setting up a consensus panel to review the statements (by completing a web-based survey, attending a face-to-face meeting to discuss survey results and modify the survey to reflect group discussion and completing the modified survey to determine which statements were in consensus). PARTICIPANTS Formulation of consensus statements: four cardiologists (two CMR and two interventional) and six non-clinical researchers. Formal consensus: seven cardiologists (two CMR and three interventional, one echocardiography and one heart failure). Forty-nine additional cardiologists completed the modified survey. RESULTS Thirty-seven draft statements describing changes in management following CMR were generated; these were condensed into 12 statements and reviewed through the formal consensus process. Three of 12 statements were classified in consensus in the first survey; these related to the role of CMR in identifying the cause of out-of-hospital cardiac arrest, providing a definitive diagnosis in patients found to have unobstructed arteries on angiography and identifying patients with left ventricular thrombus. Two additional statements were in consensus in the modified survey, relating to the ability of CMR to identify patients who have a poor prognosis after PPCI and assess ischaemia and viability in patients with multivessel disease. CONCLUSION There was consensus that CMR leads to clinically important changes in management in five subgroups of patients who activate the PPCI pathway.
Collapse
Affiliation(s)
- Maria Pufulete
- Clinical Trials and Evaluation Unit, University of Bristol, Bristol, UK
| | - Rachel C Brierley
- Clinical Trials and Evaluation Unit, University of Bristol, Bristol, UK
| | - Chiara Bucciarelli-Ducci
- NIHR Bristol Cardiovascular Research Unit, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - John P Greenwood
- Multidisciplinary Cardiovascular Research Centre and Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Stephen Dorman
- NIHR Bristol Cardiovascular Research Unit, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - Jessica Harris
- Clinical Trials and Evaluation Unit, University of Bristol, Bristol, UK
| | - Elisa McAlindon
- Department of Cardiology, New Cross Hospital, Wolverhampton, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, University of Bristol, Bristol, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, University of Bristol, Bristol, UK
| |
Collapse
|
26
|
Non-infarct related artery revascularization in ST-segment elevation myocardial infarction patients with multivessel disease. Curr Opin Cardiol 2017; 32:600-607. [PMID: 28617684 DOI: 10.1097/hco.0000000000000427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Multivessel disease (MVD) is common in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) and is associated with significant risk of future cardiovascular (CV) events including short and longer-term mortality. In this review, we examine the pathophysiologic construct contributing to adverse prognosis of MVD in STEMI, relevant available evidence that currently guides the management of the noninfarct-related artery (IRA) stenosis and define the remaining knowledge gaps for future studies. RECENT FINDINGS Results of recent small sized randomized trials, when pooled, suggest improvement in CV outcomes including CV mortality and repeat revascularization with revascularization of the non-IRA stenosis compared with medical management alone. In addition, there does not appear to be an increase in bleeding, contrast-induced nephropathy or stroke, as suggested by earlier observational data. SUMMARY These recent data have led to a Class IIb recommendation in the American College of Cardiology/American Heart Association guidelines stating that non-IRA revascularization may be considered in selected patients with STEMI and MVD who are hemodynamically stable, either at the time of primary PCI or as a planned staged procedure. The ongoing COMPLETE and CULPRIT-SHOCK studies will provide additional data to further inform the role of non-IRA revascularization and its timing in the management of these patients.
Collapse
|
27
|
Cubero-Gallego H, Romaguera R, Ariza-Sole A, Gómez-Hospital JA, Cequier A. Revascularization strategies in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease: urgent or staged? Cardiovasc Diagn Ther 2017; 7:S82-S85. [PMID: 28748154 DOI: 10.21037/cdt.2017.01.15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Héctor Cubero-Gallego
- Heart Diseases Institute, Hospital de Bellvitge - IDIBELL, University of Barcelona, Barcelona, Spain
| | - Rafael Romaguera
- Heart Diseases Institute, Hospital de Bellvitge - IDIBELL, University of Barcelona, Barcelona, Spain
| | - Albert Ariza-Sole
- Heart Diseases Institute, Hospital de Bellvitge - IDIBELL, University of Barcelona, Barcelona, Spain
| | | | - Angel Cequier
- Heart Diseases Institute, Hospital de Bellvitge - IDIBELL, University of Barcelona, Barcelona, Spain
| |
Collapse
|
28
|
Barton GR, Irvine L, Flather M, McCann GP, Curzen N, Gershlick AH. Economic Evaluation of Complete Revascularization for Patients with Multivessel Disease Undergoing Primary Percutaneous Coronary Intervention. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:745-751. [PMID: 28577691 DOI: 10.1016/j.jval.2017.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 01/25/2017] [Accepted: 02/06/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To determine the cost-effectiveness of complete revascularization at index admission compared with infarct-related artery (IRA) treatment only, in patients with multivessel disease undergoing primary percutaneous coronary intervention (P-PCI) for ST-segment elevation myocardial infarction. METHODS An economic evaluation of a multicenter randomized trial was conducted, comparing complete revascularization at index admission to IRA-only P-PCI in patients with multivessel disease (12-month follow-up). Overall hospital costs (costs for P-PCI procedure(s), hospital length of stay, and any subsequent re-admissions) were estimated. Outcomes were major adverse cardiac events (MACEs, a composite of all-cause death, recurrent myocardial infarction, heart failure, and ischemia-driven revascularization) and quality-adjusted life-years (QALYs) derived from the three-level EuroQol five-dimensional questionnaire. Multiple imputation was undertaken. The mean incremental cost and effect, with associated 95% confidence intervals, the incremental cost-effectiveness ratio, and the cost-effectiveness acceptability curve were estimated. RESULTS On the basis of 296 patients, the mean incremental overall hospital cost for complete revascularization was estimated to be -£215.96 (-£1390.20 to £958.29), compared with IRA-only, with a per-patient mean reduction in MACEs of 0.170 (0.044 to 0.296) and a QALY gain of 0.011 (-0.019 to 0.041). According to the cost-effectiveness acceptability curve, the probability of complete revascularization being cost-effective was estimated to be 72.0% at a willingness-to-pay threshold value of £20,000 per QALY. CONCLUSIONS Complete revascularization at index admission was estimated to be more effective (in terms of MACEs and QALYs) and cost-effective (overall costs were estimated to be lower and complete revascularization thereby dominated IRA-only). There was, however, some uncertainty associated with this decision.
Collapse
Affiliation(s)
- Garry R Barton
- Norwich Medical School, University of East Anglia, Norwich, UK.
| | - Lisa Irvine
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; NIHR Leicester Cardiovascular Biomedical Research Unit, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK
| | - Nick Curzen
- University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine, University of Southampton, Southampton, UK
| | - Anthony H Gershlick
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; NIHR Leicester Cardiovascular Biomedical Research Unit, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK
| |
Collapse
|
29
|
Galvão Braga C, Cid-Álvarez AB, Redondo Diéguez A, Trillo-Nouche R, Álvarez Álvarez B, López Otero D, Ocaranza Sánchez R, Gestal Romaní S, González Ferreiro R, González-Juanatey JR. Revascularización multivaso o solo de la lesión culpable en pacientes con infarto de miocardio con elevación del segmento ST: análisis de un registro a 8 años. Rev Esp Cardiol 2017. [DOI: 10.1016/j.recesp.2016.09.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
|
30
|
Gaffar R, Habib B, Filion KB, Reynier P, Eisenberg MJ. Optimal Timing of Complete Revascularization in Acute Coronary Syndrome: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2017; 6:JAHA.116.005381. [PMID: 28396570 PMCID: PMC5533029 DOI: 10.1161/jaha.116.005381] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Studies have suggested that complete revascularization is superior to culprit‐only revascularization for the treatment of enzyme‐positive acute coronary syndrome. However, the optimal timing of complete revascularization remains unclear. We conducted a systematic review and meta‐analysis of randomized controlled trials comparing single‐stage complete revascularization with multistage percutaneous coronary intervention in patients with ST‐segment elevation myocardial infarction or non–ST‐segment elevation myocardial infarction with multivessel disease. Methods and Results We systematically searched the Cochrane Central Register of Controlled Trials, Embase, PubMed, and MEDLINE for randomized controlled trials comparing single‐stage complete revascularization with multistage revascularization in patients with enzyme‐positive acute coronary syndrome. The primary outcome was the incidence of major adverse cardiovascular events at longest follow‐up. Data were pooled using DerSimonian and Laird random‐effects models. Four randomized controlled trials (n=838) were included in our meta‐analysis. The risk of unplanned repeat revascularization at longest follow‐up was significantly lower in patients randomized to single‐stage complete revascularization (risk ratio, 0.68; 95% CI, 0.47–0.99). Results also suggest a trend towards lower risks of major adverse cardiovascular events for patients randomized to single‐stage revascularization at 6 months (risk ratio, 0.67; 95% CI, 0.40–1.11) and at longest follow‐up (risk ratio, 0.79; 95% CI, 0.52–1.20). Risks of mortality and recurrent myocardial infarction at longest follow‐up were also lower with single‐stage revascularization, but 95% CIs were wide and included unity. Conclusions Our results suggest that single‐stage complete revascularization is safe. There also appears to be a trend towards lower long‐term risks of mortality and major adverse cardiovascular events; however, additional randomized controlled trials are required to confirm the potential benefits of single‐stage multivessel percutaneous coronary intervention.
Collapse
Affiliation(s)
- Rouan Gaffar
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Bettina Habib
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Kristian B Filion
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Departments of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Pauline Reynier
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Mark J Eisenberg
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada .,Division of Cardiology, Jewish General Hospital, Montreal, Quebec, Canada.,Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Departments of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
31
|
Guha S, Sethi R, Ray S, Bahl VK, Shanmugasundaram S, Kerkar P, Ramakrishnan S, Yadav R, Chaudhary G, Kapoor A, Mahajan A, Sinha AK, Mullasari A, Pradhan A, Banerjee AK, Singh BP, Balachander J, Pinto B, Manjunath CN, Makhale C, Roy D, Kahali D, Zachariah G, Wander GS, Kalita HC, Chopra HK, Jabir A, Tharakan J, Paul J, Venogopal K, Baksi KB, Ganguly K, Goswami KC, Somasundaram M, Chhetri MK, Hiremath MS, Ravi MS, Das MK, Khanna NN, Jayagopal PB, Asokan PK, Deb PK, Mohanan PP, Chandra P, Girish CR, Rabindra Nath O, Gupta R, Raghu C, Dani S, Bansal S, Tyagi S, Routray S, Tewari S, Chandra S, Mishra SS, Datta S, Chaterjee SS, Kumar S, Mookerjee S, Victor SM, Mishra S, Alexander T, Samal UC, Trehan V. Cardiological Society of India: Position statement for the management of ST elevation myocardial infarction in India. Indian Heart J 2017; 69 Suppl 1:S63-S97. [PMID: 28400042 PMCID: PMC5388060 DOI: 10.1016/j.ihj.2017.03.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
| | - Rishi Sethi
- King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Saumitra Ray
- Vivekananda Institute of Medical Sciences, Kolkata, West Bengal, India
| | - Vinay K Bahl
- All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | | | - Prafula Kerkar
- Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | | | - Rakesh Yadav
- All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | | | - Aditya Kapoor
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ajay Mahajan
- Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, Maharashtra, India
| | | | | | | | - Amal Kumar Banerjee
- Institute of Post Graduate Medical Education & Research and Memorial Hospital, Kolkata, West Bengal, India
| | - B P Singh
- Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - J Balachander
- Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | - Brian Pinto
- Holy family Hospital, Mumbai, Maharashtra, India
| | - C N Manjunath
- Sri Jaydeva Institute of Cardiovascular Sciences & Research, Bangaluru, Karnataka, India
| | | | | | - Dhiman Kahali
- BM Birla Heart Research Center, Kolkata, West Bengal, India
| | | | - G S Wander
- Hero DMC Heart Institute, Ludhiana, Punjab, India
| | - H C Kalita
- Assam Medical College, Dibrugarh, Assam, India
| | | | - A Jabir
- Lisie Hospital, Kochi, Kerala, India
| | - JagMohan Tharakan
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Justin Paul
- Madras Medical College, Chennai, Tamil Nadu, India
| | - K Venogopal
- Pushpagiri Institute of Medical Sciences, Tiruvalla, Kerala, India
| | - K B Baksi
- Belle Vue Clinic, Kolkata, West Bengal, India
| | | | - Kewal C Goswami
- All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | | | - M K Chhetri
- IPGMER & SSKM Hospital, Kolkata, West Bengal, India
| | | | - M S Ravi
- Madras Medical College, Chennai, Tamil Nadu, India
| | | | | | | | - P K Asokan
- The Fatima Hospital, Calicut, Kerala, India
| | - P K Deb
- ESI Hospital, Manicktala, Kolkata, West Bengal, India
| | - P P Mohanan
- Westfort Hi-Tech Hospital, Thrissur, Kerala, India
| | | | - Col R Girish
- Command Hospital, Central Command, Lucknow, India
| | - O Rabindra Nath
- Apollo Gleneagles Heart Institute, Kolkata, West Bengal, India
| | | | - C Raghu
- Prime Hospitals, Hyderabad, India
| | | | | | - Sanjay Tyagi
- GB Pant Institute of Post Graduate Medical Education & Research, New Delhi, India
| | | | - Satyendra Tewari
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | | | | | | | - S S Chaterjee
- Indra Gandhi Institute of Cardiology, Patna, Bihar, India
| | - Soumitra Kumar
- Vivekananda Institute of Medical Sciences, Kolkata, West Bengal, India
| | | | | | - Sundeep Mishra
- All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | | | | | - Vijay Trehan
- Indo-US Super Speciality Hospital, Hyderabad, India
| |
Collapse
|
32
|
Marino M, Crimi G, Leonardi S, Ferlini M, Repetto A, Camporotondo R, Demarchi A, De Pascali I, Falcinella F, Oltrona Visconti L, De Servi S, Ferrario M, De Ferrari GM, Gnecchi M. Comparison of Outcomes of Staged Complete Revascularization Versus Culprit Lesion-Only Revascularization for ST-Elevation Myocardial Infarction and Multivessel Coronary Artery Disease. Am J Cardiol 2017; 119:508-514. [PMID: 28007297 DOI: 10.1016/j.amjcard.2016.10.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 10/31/2016] [Accepted: 10/31/2016] [Indexed: 01/03/2023]
Abstract
The management of noninfarct-related arteries in patients with ST-elevation myocardial infarction (STEMI) and multivessel coronary disease (MVD) is still debated. We evaluated the prognostic impact of staged complete revascularization with percutaneous coronary intervention (PCI) in STEMI patients with MVD admitted to our hospital from 2005 to 2013. Patients undergoing staged complete revascularization (n = 300) were compared with 1:1 propensity score-matched patients with culprit lesion-only treatment (n = 300). We considered a composite primary end point of all-cause death, myocardial infarction, and urgent PCI. Secondary end points included components of the primary, cardiovascular death, any PCI excluding staged PCI. We also performed an analysis including only patients surviving at least 5 days. The median follow-up was 553 days. The primary end point occurred in 10.3% of patients in the staged complete revascularization group and in 16.3% of patients in the culprit lesion-only group (hazard ratio 0.61, 95% CI 0.38 to 0.95, p = 0.031). Although this difference was no longer significant when considering only the survivors at day 5, all-cause and cardiovascular mortalities were still reduced in the staged complete revascularization group. Complete revascularization was associated with a better outcome (hazard ratio 0.35, 95% CI 0.17 to 0.63, p = 0.005) if performed within 30 days of STEMI. In conclusion, compared with culprit lesion-only revascularization, in STEMI patients with MVD undergoing primary PCI, an approach of staged complete revascularization was associated with a better outcome.
Collapse
|
33
|
Complete or Culprit-Only Revascularization for Patients With Multivessel Coronary Artery Disease Undergoing Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2017; 10:315-324. [DOI: 10.1016/j.jcin.2016.11.047] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 11/22/2016] [Accepted: 11/30/2016] [Indexed: 01/24/2023]
|
34
|
Binder RK, Maier W, Lüscher TF. Multi-vessel revascularization in ST-segment elevation myocardial infarction: where do we stand? Eur Heart J 2017; 37:217-20. [PMID: 26768212 DOI: 10.1093/eurheartj/ehv722] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In summary, current evidence suggests that it appears to be better to do something rather than nothing. However, the question of single vs. staged complete revascularization, the best timing of the staged PCI (during the index admission or within weeks) and the question of stratification for evidence of ischaemia remain to be answered in upcoming trials. Meanwhile, complete revascularization should not be routinely performed ad-hoc, but based on individual and careful patient and lesion assessments
Collapse
Affiliation(s)
- Ronald K Binder
- European Heart Journal, Zurich Heart House, Careum Campus, Moussonstreet 4, 8091 Zurich, Switzerland
| | - Willibald Maier
- European Heart Journal, Zurich Heart House, Careum Campus, Moussonstreet 4, 8091 Zurich, Switzerland
| | - Thomas F Lüscher
- European Heart Journal, Zurich Heart House, Careum Campus, Moussonstreet 4, 8091 Zurich, Switzerland
| |
Collapse
|
35
|
Nagaraja V, Ooi SY, Nolan J, Large A, De Belder M, Ludman P, Bagur R, Curzen N, Matsukage T, Yoshimachi F, Kwok CS, Berry C, Mamas MA. Impact of Incomplete Percutaneous Revascularization in Patients With Multivessel Coronary Artery Disease: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2016; 5:JAHA.116.004598. [PMID: 27986755 PMCID: PMC5210416 DOI: 10.1161/jaha.116.004598] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Up to half of patients undergoing percutaneous coronary intervention have multivessel coronary artery disease (MVD) with conflicting data regarding optimal revascularization strategy in such patients. This paper assesses the evidence for complete revascularization (CR) versus incomplete revascularization in patients undergoing percutaneous coronary intervention, and its prognostic impact using meta‐analysis. Methods and Results A search of PubMed, EMBASE, MEDLINE, Current Contents Connect, Google Scholar, Cochrane library, Science Direct, and Web of Science was conducted to identify the association of CR in patients with multivessel coronary artery disease undergoing percutaneous coronary intervention with major adverse cardiac events and mortality. Random‐effects meta‐analysis was used to estimate the odds of adverse outcomes. Meta‐regression analysis was conducted to assess the relationship with continuous variables and outcomes. Thirty‐eight publications that included 156 240 patients were identified. Odds of death (OR 0.69, 95% CI 0.61‐0.78), repeat revascularization (OR 0.60, 95% CI 0.45‐0.80), myocardial infarction (OR 0.64, 95% CI 0.50‐0.81), and major adverse cardiac events (OR 0.63, 95% CI 0.50‐0.79) were significantly lower in the patients who underwent CR. These outcomes were unchanged on subgroup analysis regardless of the definition of CR. Similar findings were recorded when CR was studied in the chronic total occlusion (CTO) subgroup (OR 0.65, 95% CI 0.53‐0.80). A meta‐regression analysis revealed a negative relationship between the OR for mortality and the percentage of CR. Conclusion CR is associated with reduced risk of mortality and major adverse cardiac events, irrespective of whether an anatomical or a score‐based definition of incomplete revascularization is used, and this magnitude of risk relates to degree of CR. These results have important implications for the interventional management of patients with multivessel coronary artery disease.
Collapse
Affiliation(s)
- Vinayak Nagaraja
- Department of Cardiology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Sze-Yuan Ooi
- Department of Cardiology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - James Nolan
- Royal Stoke University Hospital, University Hospitals of North Midlands, Stoke-on-Trent, United Kingdom.,Keele Cardiovascular Research Group, Institute of Science and Technology in Medicine, University of Keele, Stoke-on-Trent, United Kingdom
| | - Adrian Large
- Royal Stoke University Hospital, University Hospitals of North Midlands, Stoke-on-Trent, United Kingdom
| | - Mark De Belder
- The James Cook University Hospital, Middlesbrough, United Kingdom
| | - Peter Ludman
- Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Rodrigo Bagur
- Division of Cardiology, Department of Medicine and Department of Epidemiology & Biostatistics, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Nick Curzen
- University Hospital Southampton & Faculty of Medicine University of Southampton, United Kingdom
| | - Takashi Matsukage
- Division of Cardiology, Tokai University School of Medicine, Isehara, Japan
| | | | - Chun Shing Kwok
- Royal Stoke University Hospital, University Hospitals of North Midlands, Stoke-on-Trent, United Kingdom.,Keele Cardiovascular Research Group, Institute of Science and Technology in Medicine, University of Keele, Stoke-on-Trent, United Kingdom
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom
| | - Mamas A Mamas
- Royal Stoke University Hospital, University Hospitals of North Midlands, Stoke-on-Trent, United Kingdom .,Keele Cardiovascular Research Group, Institute of Science and Technology in Medicine, University of Keele, Stoke-on-Trent, United Kingdom
| |
Collapse
|
36
|
Meta-Analysis Comparing Complete Revascularization Versus Infarct-Related Only Strategies for Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Artery Disease. Am J Cardiol 2016; 118:1466-1472. [PMID: 27642115 DOI: 10.1016/j.amjcard.2016.08.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 08/09/2016] [Accepted: 08/09/2016] [Indexed: 01/01/2023]
Abstract
Several recent randomized controlled trials (RCTs) demonstrated better outcomes with multivessel complete revascularization (CR) than with infarct-related artery-only revascularization (IRA-OR) in patients with ST-segment elevation myocardial infarction. It is unclear whether CR should be performed during the index procedure (IP) at the time of primary percutaneous coronary intervention (PCI) or as a staged procedure (SP). Therefore, we performed a pairwise meta-analysis using a random-effects model and network meta-analysis using mixed-treatment comparison models to compare the efficacies of 3 revascularization strategies (IRA-OR, CR-IP, and CR-SP). Scientific databases and websites were searched to find RCTs. Data from 9 RCTs involving 2,176 patients were included. In mixed-comparison models, CR-IP decreased the risk of major adverse cardiac events (MACEs; odds ratio [OR] 0.36, 95% CI 0.25 to 0.54), recurrent myocardial infarction (MI; OR 0.50, 95% CI 0.24 to 0.91), revascularization (OR 0.24, 95% CI 0.15 to 0.38), and cardiovascular (CV) mortality (OR 0.44, 95% CI 0.20 to 0.87). However, only the rates of MACEs, MI, and CV mortality were lower with CR-SP than with IRA-OR. Similarly, in direct-comparison meta-analysis, the risk of MI was 66% lower with CR-IP than with IRA-OR, but this advantage was not seen with CR-SP. There were no differences in all-cause mortality between the 3 revascularization strategies. In conclusion, this meta-analysis shows that in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease, CR either during primary PCI or as an SP results in lower occurrences of MACE, revascularization, and CV mortality than IRA-OR. CR performed during primary PCI also results in lower rates of recurrent MI and seems the most efficacious revascularization strategy of the 3.
Collapse
|
37
|
Galvão Braga C, Cid-Álvarez AB, Redondo Diéguez A, Trillo-Nouche R, Álvarez Álvarez B, López Otero D, Ocaranza Sánchez R, Gestal Romaní S, González Ferreiro R, González-Juanatey JR. Multivessel Versus Culprit-only Percutaneous Coronary Intervention in ST-segment Elevation Acute Myocardial Infarction: Analysis of an 8-year Registry. ACTA ACUST UNITED AC 2016; 70:425-432. [PMID: 27825718 DOI: 10.1016/j.rec.2016.09.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 09/16/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION AND OBJECTIVES The optimal treatment of patients with multivessel coronary artery disease and ST-segment elevation acute myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (PCI) is controversial. The aim of this study was to access the prognostic impact of multivessel PCI vs culprit vessel-only PCI in real-world patients with STEMI and multivessel disease. METHODS This was a retrospective cohort study of 1499 patients with STEMI diagnosis who underwent primary PCI between January 2008 and December 2015. About 40.8% (n=611) patients had multivessel disease. We performed a propensity score matched analysis to obtain 2 groups of 215 patients paired according to whether or not they had undergone multivessel PCI or culprit vessel-only PCI. RESULTS During follow-up (median, 2.36 years), after propensity score matching, patients who underwent multivessel PCI had lower rates of mortality (5.1% vs 11.6%; Peto-Peto P=.014), unplanned repeat revascularization (7.0% vs 12.6%; Peto-Peto P=.043) and major acute cardiovascular events (22.0% vs 30.8%; Peto-Peto P=.049). These patients also showed a trend to a lower incidence of myocardial infarction (4.2% vs 6.1%; Peto-Peto P=.360). CONCLUSIONS In real-world patients presenting with STEMI and multivessel coronary artery disease, a multivessel PCI strategy was associated with lower rates of mortality, unplanned repeat revascularization, and major acute cardiovascular events.
Collapse
Affiliation(s)
- Carlos Galvão Braga
- Servicio de Cardiología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Serviço de Cardiologia, Hospital de Braga, Braga, Portugal.
| | - Ana Belén Cid-Álvarez
- Servicio de Cardiología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Alfredo Redondo Diéguez
- Servicio de Cardiología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Ramiro Trillo-Nouche
- Servicio de Cardiología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Belén Álvarez Álvarez
- Servicio de Cardiología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Diego López Otero
- Servicio de Cardiología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Raymundo Ocaranza Sánchez
- Servicio de Cardiología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Santiago Gestal Romaní
- Servicio de Cardiología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Rocío González Ferreiro
- Servicio de Cardiología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - José R González-Juanatey
- Servicio de Cardiología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| |
Collapse
|
38
|
Villablanca PA, Briceno DF, Massera D, Hlinomaz O, Lombardo M, Bortnick AE, Menegus MA, Pyo RT, Garcia MJ, Mookadam F, Ramakrishna H, Wiley J, Faggioni M, Dangas GD. Culprit-lesion only versus complete multivessel percutaneous intervention in ST-elevation myocardial infarction: A systematic review and meta-analysis of randomized trials. Int J Cardiol 2016; 220:251-9. [DOI: 10.1016/j.ijcard.2016.06.098] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 06/11/2016] [Accepted: 06/21/2016] [Indexed: 11/25/2022]
|
39
|
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]
|
40
|
Mangion K, Carrick D, Hennigan BW, Payne AR, McClure J, Mason M, Das R, Wilson R, Edwards RJ, Petrie MC, McEntegart M, Eteiba H, Oldroyd KG, Berry C. Infarct size and left ventricular remodelling after preventive percutaneous coronary intervention. Heart 2016; 102:1980-1987. [PMID: 27504003 PMCID: PMC5256395 DOI: 10.1136/heartjnl-2015-308660] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 06/17/2016] [Accepted: 06/22/2016] [Indexed: 11/05/2022] Open
Abstract
Objective We hypothesised that, compared with culprit-only primary percutaneous coronary intervention (PCI), additional preventive PCI in selected patients with ST-elevation myocardial infarction with multivessel disease would not be associated with iatrogenic myocardial infarction, and would be associated with reductions in left ventricular (LV) volumes in the longer term. Methods In the preventive angioplasty in myocardial infarction trial (PRAMI; ISRCTN73028481), cardiac magnetic resonance (CMR) was prespecified in two centres and performed (median, IQR) 3 (1, 5) and 209 (189, 957) days after primary PCI. Results From 219 enrolled patients in two sites, 84% underwent CMR. 42 (50%) were randomised to culprit-artery-only PCI and 42 (50%) were randomised to preventive PCI. Follow-up CMR scans were available in 72 (86%) patients. There were two (4.8%) cases of procedure-related myocardial infarction in the preventive PCI group. The culprit-artery-only group had a higher proportion of anterior myocardial infarctions (MIs) (55% vs 24%). Infarct sizes (% LV mass) at baseline and follow-up were similar. At follow-up, there was no difference in LV ejection fraction (%, median (IQR), (culprit-artery-only PCI vs preventive PCI) 51.7 (42.9, 60.2) vs 54.4 (49.3, 62.8), p=0.23), LV end-diastolic volume (mL/m2, 69.3 (59.4, 79.9) vs 66.1 (54.7, 73.7), p=0.48) and LV end-systolic volume (mL/m2, 31.8 (24.4, 43.0) vs 30.7 (23.0, 36.3), p=0.20). Non-culprit angiographic lesions had low-risk Syntax scores and 47% had non-complex characteristics. Conclusions Compared with culprit-only PCI, non-infarct-artery MI in the preventive PCI strategy was uncommon and LV volumes and ejection fraction were similar.
Collapse
Affiliation(s)
- Kenneth Mangion
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Dunbartonshire, UK
| | - David Carrick
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Dunbartonshire, UK
| | - Barry W Hennigan
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Dunbartonshire, UK
| | - Alexander R Payne
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Dunbartonshire, UK
| | - John McClure
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Maureen Mason
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Dunbartonshire, UK
| | - Rajiv Das
- Therapeutics and Cardiac Research Team, Freeman Hospital, Newcastle upon Tyne, UK
| | - Rebecca Wilson
- Therapeutics and Cardiac Research Team, Freeman Hospital, Newcastle upon Tyne, UK
| | - Richard J Edwards
- Therapeutics and Cardiac Research Team, Freeman Hospital, Newcastle upon Tyne, UK
| | - Mark C Petrie
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Dunbartonshire, UK
| | - Margaret McEntegart
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Dunbartonshire, UK
| | - Hany Eteiba
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Dunbartonshire, UK
| | - Keith G Oldroyd
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Dunbartonshire, UK
| | - Colin Berry
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Dunbartonshire, UK
| |
Collapse
|
41
|
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.
Collapse
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
| |
Collapse
|
42
|
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.
Collapse
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
| |
Collapse
|
43
|
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.
Collapse
|
44
|
Soverow J, Parikh MA. Acute Myocardial Infarction/Thrombectomy. Interv Cardiol Clin 2016; 5:259-269. [PMID: 28582209 DOI: 10.1016/j.iccl.2015.12.010] [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: 12/01/2022]
Abstract
This article focuses on specialized techniques and devices used in the most challenging cases of acute myocardial infarction. Areas where high-quality evidence is either clear or absent are avoided. Controversies in the use of support or thrombectomy devices, the addition of adjunct pharmacology, and the decision to treat nonculprit lesions are discussed. Recent years have seen a shift in guidelines to downgrading the use of assist devices in cardiogenic shock and aspiration thrombectomy, whereas consideration of nonculprit coronary intervention has been revived. These changes come in the wake of a series of large, practice-changing clinical trials.
Collapse
Affiliation(s)
- Jonathan Soverow
- Center for Interventional Vascular Therapy, Columbia-Presbyterian Hospital, 161 Fort Washington Avenue, Herbert Irving Pavilion, 6th Floor, New York, NY 10032, USA.
| | - Manish A Parikh
- Center for Interventional Vascular Therapy, Columbia-Presbyterian Hospital, 161 Fort Washington Avenue, Herbert Irving Pavilion, 6th Floor, New York, NY 10032, USA
| |
Collapse
|
45
|
|
46
|
Wang TY, McCoy LA, Bhatt DL, Rao SV, Roe MT, Resnic FS, Cavender MA, Messenger JC, Peterson ED. Multivessel vs culprit-only percutaneous coronary intervention among patients 65 years or older with acute myocardial infarction. Am Heart J 2016; 172:9-18. [PMID: 26856210 DOI: 10.1016/j.ahj.2015.10.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 10/22/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Older adults presenting with acute myocardial infarction (MI) often have multivessel coronary artery disease amenable to percutaneous coronary intervention (PCI), yet the risks of multivessel intervention may outweigh potential benefits in these patients. We sought to determine if nonculprit intervention during the index PCI is associated with better outcomes among older patients with acute MI and multivessel disease. METHODS We examined 19,271 ST-segment elevation MI (STEMI) and 31,361 non-STEMI (NSTEMI) patients 65years or older with multivessel disease in a linked CathPCI Registry-Medicare database, excluding patients with prior coronary artery bypass grafting, left main disease, or cardiogenic shock. Using inverse probability-weighted propensity adjustment, we compared mortality between patients receiving culprit-only vs multivessel intervention during the index PCI procedure. RESULTS Most older MI patients (91% STEMI and 74% NSTEMI) received culprit-only intervention during the index PCI. Among STEMI patients, multivessel intervention during the index PCI was associated with higher 30-day mortality (8.3% vs 6.3%, adjusted hazard ratio [HR] 1.36, 95% CI 1.14-1.62) than culprit-only intervention, and this trend persisted at 1year (13.8% vs 12.2%, adjusted HR 1.14, 95% CI 0.99-1.31). No significant mortality differences were observed among NSTEMI patients at 30days (3.4% vs 4.1%, adjusted HR 1.01, 95% CI 0.88-1.15) or at 1year (10.1% vs 10.8%, adjusted HR 0.99, 95% CI 0.91-1.08). CONCLUSIONS Nonculprit intervention during the index PCI was associated with worse outcomes among STEMI patients, but not NSTEMI patients.
Collapse
|
47
|
Gershlick AH, Khan JN, Kelly DJ, Greenwood JP, Sasikaran T, Curzen N, Blackman DJ, Dalby M, Fairbrother KL, Banya W, Wang D, Flather M, Hetherington SL, Kelion AD, Talwar S, Gunning M, Hall R, Swanton H, McCann GP. Reply: Complete Revascularization in Patients Undergoing Primary Percutaneous Coronary Intervention for STEMI: Is It Really What We Should Be Doing? J Am Coll Cardiol 2015; 66:332-333. [PMID: 26184630 DOI: 10.1016/j.jacc.2015.04.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 04/28/2015] [Indexed: 11/26/2022]
|