Multivessel Versus Culprit Vessel-Only Percutaneous Coronary Intervention Among Patients With Acute Myocardial Infarction: Insights From the TRANSLATE-ACS Observational Study

Complete revascularization in acute myocardial infarction: a clinical review

In patients with ST segment elevation and non-ST elevation myocardial infarction (MI), multivessel (MV) coronary artery disease is found in approximately 50%, leading to worse clinical outcomes. Recent data have suggested that complete revascularization with MV percutaneous coronary intervention is associated with a reduced risk of major adverse cardiovascular events as compared to culprit vessel-only revascularization. However, the optimal timing of MV intervention, appropriate non-culprit lesion assessment, and the best revascularization strategy in specific subsets such as cardiogenic shock remain to be established. This review article summarizes current evidence on revascularization strategies in patients with acute MI and MV disease.

Culprit versus Complete Revascularization during the Initial Intervention in Patients with Acute Coronary Syndrome Using a Virtual Treatment Planning Tool: Results of a Single-Center Pilot Study

Background and Objectives: The revascularization strategy for percutaneous coronary intervention (PCI) in patients with multivessel (MV) acute coronary syndrome (ACS) remains controversial. Certain gaps in the evidence are related to the optimal timing of non-culprit lesion revascularization and the utility of instantaneous wave-free ratio (iFR) in the management of MV ACS intervention. The major benefits of iFR utilization in MV ACS patients in one-stage complete revascularization are: (1) the possibility to virtually plan the PCI, both the location and the extension of the necessary stenting to achieve the prespecified final hemodynamic result; (2) the opportunity to validate the final hemodynamic result of the PCI, both in culprit artery and all non-culprit arteries and (3) the value of obliviating the uncomfortable, costly, time consuming and sometimes deleterious effects from Adenosine, as there is no requirement for administration. Thus, iFR use fosters the achievement of physiologically appropriate complete revascularization in MV ACS patients during acute hospitalization. Materials and Methods: This pilot study was aimed to test the feasibility of a randomized trial research protocol as well as to assess patient safety signals of co-registration iFR-guided one-stage complete revascularization compared with that of standard staged angiography-guided PCI in de novo patients with MV ACS. This was a single-center, prospective, randomized, open-label clinical trial consecutively screening patients with ACS for MV disease. The intervention strategy of interest was iFR-guided physiologically complete one-stage revascularization, in which the virtual PCI planning of non-culprit lesions and the intervention itself were performed in one stage directly following treatment of the culprit lesion and other critical stenosis of more than ninety percent. Seventeen patients were recruited and completed the 3-month follow-up. Results: Index PCI duration was significantly longer while the volume of contrast media delivered in index PCI was significantly greater in the iFR-guided group than in the angiography-guided group (119.4 ± 40.7 vs. 47 ± 15.5 min, p = 0.004; and 360 ± 97.9 vs. 192.5 ± 52.8 mL, p = 0.003). There were no significant differences in PCI-related major adverse cardiovascular events (MACE) between the groups during acute hospitalization and at 3-months follow-up. One-stage iFR-guided PCI requires fewer PCI attempts until complete revascularization than does angiography-guided staged PCI. Conclusions: Complete revascularization with the routine use of the virtual planning tool in one-stage iFR-guided PCI is a feasible practical strategy in an everyday Cath lab environment following the protocol designed for the study. No statistically significant safety signals were documented in the number of PCI related MACE during the 3-month follow-up.

Complete Revascularization vs Culprit Lesion-Only Percutaneous Coronary Intervention for Angina-Related Quality of Life in Patients With ST-Segment Elevation Myocardial Infarction: Results From the COMPLETE Randomized Clinical Trial

Importance

In patients with multivessel coronary artery disease (CAD) presenting with ST-segment elevation myocardial infarction (STEMI), complete revascularization reduces major cardiovascular events compared with culprit lesion-only percutaneous coronary intervention (PCI). Whether complete revascularization also improves angina-related health status is unknown.

Objective

To determine whether complete revascularization improves angina status in patients with STEMI and multivessel CAD.

Design, Setting, and Participants

This secondary analysis of a randomized, multinational, open label trial of patient-reported outcomes took place in 140 primary PCI centers in 31 countries. Patients presenting with STEMI and multivessel CAD were randomized between February 1, 2013, and March 6, 2017. Analysis took place between July 2021 and December 2021.

Interventions

Following PCI of the culprit lesion, patients with STEMI and multivessel CAD were randomized to receive either complete revascularization with additional PCI of angiographically significant nonculprit lesions or to no further revascularization.

Main Outcomes and Measures

Seattle Angina Questionnaire Angina Frequency (SAQ-AF) score (range, 0 [daily angina] to 100 [no angina]) and the proportion of angina-free individuals by study end.

Results

Of 4041 patients, 2016 were randomized to complete revascularization and 2025 to culprit lesion-only PCI. The mean (SD) age of patients was 62 (10.7) years, and 3225 (80%) were male. The mean (SD) SAQ-AF score increased from 87.1 (17.8) points at baseline to 97.1 (9.7) points at a median follow-up of 3 years in the complete revascularization group (score change, 9.9 [95% CI, 9.0-10.8]; P < .001) compared with an increase of 87.2 (18.4) to 96.3 (10.9) points (score change, 8.9 [95% CI, 8.0-9.8]; P < .001) in the culprit lesion-only group (between-group difference, 0.97 points [95% CI, 0.27-1.67]; P = .006). Overall, 1457 patients (87.5%) were free of angina (SAQ-AF score, 100) in the complete revascularization group compared with 1376 patients (84.3%) in the culprit lesion-only group (absolute difference, 3.2% [95% CI, 0.7%-5.7%]; P = .01). This benefit was observed mainly in patients with nonculprit lesion stenosis severity of 80% or more (absolute difference, 4.7%; interaction P = .02).

Conclusions and Relevance

In patients with STEMI and multivessel CAD, complete revascularization resulted in a slightly greater proportion of patients being angina-free compared with a culprit lesion-only strategy. This modest incremental improvement in health status is in addition to the established benefit of complete revascularization in reducing cardiovascular events.

Implications of Payment for Acute Myocardial Infarctions as a 90-Day Bundled Single Episode of Care: A Cost of Illness Analysis

OBJECTIVES

Evaluate the cost of illness associated with the 90-day period following acute myocardial infarction (AMI) and the implication of care pathway (percutaneous coronary intervention [PCI] vs medical management [MM]), in order to assess the potential financial risk incurred by providers for AMI as an episode of care.

PERSPECTIVE

Reimbursement payment systems for acute care episodes are shifting from 30-day to 90-day bundled payment models. Since follow-up care and readmissions beyond the early days/weeks post-AMI are common, financial risk may be transferred to providers.

SETTING

AMI hospitalization Centers for Medicare & Medicaid Services (CMS) standard analytical files between 10/1/2015 and 9/30/2016 were reviewed.

METHODS

Included patients were Medicare beneficiaries with a primary diagnosis of AMI subsequently treated with either PCI or MM. Payments were standardized to remove geographic variation and separated into reimbursements for services during the hospitalization and from discharge to 90 days post-discharge. Results were stratified by Medicare Severity Diagnosis Related Groups (MS-DRGs) individually and grouped between patients treated with MM and PCI. Risk-adjusted likelihood of utilization of post-acute nursing care and all-cause readmission was assessed by logistic regression.

RESULTS

A total of 96,546 patients were included in the analysis. The highest total mean payment (US$32,714) was for MS-DRG 248 (PCI with non-drug-eluting stent with major complication or comorbidity). Total payments were similar between MM and PCI patients, but MM patients incurred the majority of costs in the post-acute period after discharge, with the converse true for PCI patients. MM without catheterization was associated with a twofold increase in risk of requiring post-acute nursing care and 90-day readmission versus PCI (odds ratio [95% confidence interval]: 2.01 [1.92-2.11] and 2.17 [2.08-2.27]). Smaller hospital size, diabetes, peripheral arterial disease, prior AMI, and multivessel disease were predictors of higher healthcare utilization.

CONCLUSIONS

MS-DRGs associated with the lowest reimbursements (and presumably, lowest costs of inpatient care) incur the highest post-discharge expenditures. As the CMS Bundled Payment for Care Improvement and similar programs are implemented, there will be a need to account for heterogeneous post-discharge care costs. Video abstract (MP4 274659 KB).

Complete versus culprit-only strategy in older MI patients with multivessel disease

AIMS

The revascularization strategy to pursue in older myocardial infarction (MI) patients with multivessel disease (MVD) is currently unknown. For this reason, while waiting for the results of dedicated trials, we sought to compare a complete versus a culprit-only strategy in older MI patients by merging data from four registries.

METHODS AND RESULTS

The inclusion criteria for the target population of the present study were (i) age ≥ 75 years; (ii) MI (STE or NSTE); (iii) MVD; (iv) successful treatment of culprit lesion. Propensity scores (PS) were derived using logistic regression (backward stepwise selection, p < 0.2). The primary outcome was all-cause mortality. Secondary outcomes were cardiovascular (CV) death, MI, and major bleeding. Multivariable adjustment included the PS and inverse probability of treatment weighting (IPTW). The Kaplan-Meier plots were weighted for IPT. Among 2087 patients included, 1362 (65%) received culprit-only treatment whereas 725 (35%) complete revascularization. The mean age was 81.5 years, while the mean follow-up was 419 ± 284 days. Seventy-four patients (10%) died in the complete group and 223 in the culprit-only one (16%). The adjusted cumulative 1-year mortality was 9.7% in the complete and 12.9% in the culprit-only group (adjusted HR: 0.67, 95% CI: 0.50-0.89). Complete revascularization was associated with lower incidence of CV death (adjusted HR: 0.68, 95% CI: 0.48-0.95) and MI (adjusted HR 0.67, 95% CI: 0.48-0.95).

CONCLUSIONS

Culprit-only is the default strategy in older MI patients with MVD. In our analysis, complete revascularization was associated with lower all-cause and CV mortality and with a lower MI rate.

Management of multivessel coronary artery disease in patients with non-ST-elevation myocardial infarction: a complex path to precision medicine

Recent analyses suggest the incidence of acute coronary syndrome is declining in high- and middle-income countries. Despite this, overall rates of non-ST-elevation myocardial infarction (NSTEMI) continue to rise. Furthermore, NSTEMI is a greater contributor to mortality after hospital discharge than ST-elevation myocardial infarction (STEMI). Patients with NSTEMI are often older, comorbid and have a high likelihood of multivessel coronary artery disease (MVD), which is associated with worse clinical outcomes. Currently, optimal treatment strategies for MVD in NSTEMI are less well established than for STEMI or stable coronary artery disease. Specifically, in relation to percutaneous coronary intervention (PCI) there is a paucity of randomized, prospective data comparing multivessel and culprit lesion-only PCI. Given the heterogeneous pathological basis for NSTEMI with MVD, an approach of complete revascularization may not be appropriate or necessary in all patients. Recognizing this, this review summarizes the limited evidence base for the interventional management of non-culprit disease in NSTEMI by comparing culprit-only and multivessel PCI strategies. We then explore how a personalized, precise approach to investigation, therapy and follow up may be achieved based on patient-, disease- and lesion-specific factors.

Complete Versus Culprit-Only Revascularization in Patients Presenting With ST-Segment Elevation Myocardial Infarction: A Meta-Analysis of Randomized Control Trials

BACKGROUND

In patients with ST elevation myocardial infarction (STEMI), primary percutaneous coronary intervention (PCI) of the culprit vessel is the preferred treatment option. For patients with multivessel disease, the benefit of revascularization of the non-culprit artery is not well known. This meta-analysis aims to assess the efficacy and safety of complete versus culprit vessel only revascularization.

METHODS

Randomized control trials (RCT) that compared head-to-head complete versus culprit-vessel only revascularization in STEMI patients and reported main outcomes of interest such as mortality, myocardial infarction, and revascularization, were included in this meta-analysis.

RESULTS

We found ten RCTs satisfying our inclusion criteria. Data was extracted and used to estimate the risk ratio (RR) and 95% confidence interval (CI) for dichotomous variables. Our study included 7030 patients (3426 complete revascularization, and 3604 culprit-only revascularization). Complete revascularization (CR) (both immediate and staged) significantly reduced the risk of MACE compared with culprit only (CO) revascularization (10.7% vs 20.1%, RR 0.53; 95% CI 0.43 to 0.64; P < 0.0001), reinfarction (5.0% vs 6.9%, RR 0.69; 95 CI 0.51 to 0.93; P < 0.01), and revascularization (4.2% vs 12.7%, RR 0.37; 95 CI 0.26 to 0.54; P < 0.0001). Our analysis did not find any significant difference in all-cause mortality between CR and CO (4.6% vs 5.0%, RR 0.89; 95 CI 0.72 to 0.1.10; P = 0.27).

CONCLUSION

In conclusion, complete revascularization was associated with a significant reduction in major adverse cardiovascular events, revascularization and reinfarction.

Older Adults in the Cardiac Intensive Care Unit: Factoring Geriatric Syndromes in the Management, Prognosis, and Process of Care: A Scientific Statement From the American Heart Association

Longevity is increasing, and more adults are living to the stage of life when age-related biological factors determine a higher likelihood of cardiovascular disease in a distinctive context of concurrent geriatric conditions. Older adults with cardiovascular disease are frequently admitted to cardiac intensive care units (CICUs), where care is commensurate with high age-related cardiovascular disease risks but where the associated geriatric conditions (including multimorbidity, polypharmacy, cognitive decline and delirium, and frailty) may be inadvertently exacerbated and destabilized. The CICU environment of procedures, new medications, sensory overload, sleep deprivation, prolonged bed rest, malnourishment, and sleep is usually inherently disruptive to older patients regardless of the excellence of cardiovascular disease care. Given these fundamental and broad challenges of patient aging, CICU management priorities and associated decision-making are particularly complex and in need of enhancements. In this American Heart Association statement, we examine age-related risks and describe some of the distinctive dynamics pertinent to older adults and emerging opportunities to enhance CICU care. Relevant assessment tools are discussed, as well as the need for additional clinical research to best advance CICU care for the already dominating and still expanding population of older adults.

Network Meta-Analysis of Percutaneous Intervention-Based Revascularization Strategies for ST-Elevation Myocardial Infarction and Concomitant Multi-Vessel Disease

BACKGROUND

In patients with ST elevation myocardial infarction (STEMI) and concomitant multi-vessel disease (MVD), primary percutaneous coronary intervention (PCI) of the culprit vessel is the preferred reperfusion strategy. However, optimum timing of revascularization for non-culprit artery is unclear. In this Bayesian network meta-analysis (NMA), we compared different PCI-based revascularization strategies in STEMI patients with MVD.

METHODS

11 randomized controlled trials (RCTs) were selected using MEDLINE, EMBASE and CENTRAL (Inception to September 2017). For all outcomes, median estimate of odds ratio from posterior distribution with corresponding 95% credible interval was calculated. The Surface under the Cumulative Ranking Curve (SUCRA) metric was used to estimate the relative ranking probability of each intervention. Sensitivity analysis was conducted by excluding the RCTs in which the staged intervention was performed after two weeks of the index procedure or post discharge.

RESULTS

In this NMA of 3172 patients, CR-I (instant complete revascularization) was associated with 40% relative risk reduction in all-cause mortality compared with IRA (infarct related artery) [0.60 (0.31-0.89)]. CR-I was superior to CR-S (staged complete revascularization) [0.42 (0.22-0.70)] and IRA [0.50(0.29-0.72)] in reducing the risk of re- infarction. Both CR-I and CR-S significantly reduced the risk of repeat revascularization compared to IRA, whereas the risk of CIN (contrast induced nephropathy) and major bleeding was similar across all interventions. Sensitivity analysis showed, that CR-I was a better strategy compared with CR-S [0.34 (0.12-0.74)] and IRA (0.60 [0.36-0.97]) in reducing all-cause mortality.

CONCLUSIONS

In this NMA, CR-I was associated with reduction in all-cause mortality and re- infarction compared with IRA.

Comparison of 30-Day MACE between Immediate versus Staged Complete Revascularization in Acute Myocardial Infarction with Multivessel Disease, and the Effect of Coronary Lesion Complexity

Background and objective: In patients with acute myocardial infarction and multivessel disease, the timing of intervention to non-culprit lesions is still a matter of debate, especially in patients without shock. This study aimed to compare the effect of multivessel intervention, performed at index percutaneous coronary intervention (PCI) (MVI-I) or index hospitalization (MVI-S), on the 30-day results of acute myocardial infarction (AMI), and to investigate the effect of coronary lesion complexity assessed by the Syntax (Sx) score on the timing of multivessel intervention. Materials and methods: We enrolled 180 patients with MVI-I, and 425 patients with MVI-S. The major adverse cardiovascular events (MACE) for this study were identified as mortality, nonfatal myocardial infarction, nonfatal stroke, acute heart failure, ischemia driven revascularization, major bleeding, and acute renal failure developed within 30 days. Results: The unadjusted MACE rates at 30 days were 11.2% and 5% among those who underwent MVI-I and MVI-S, respectively (OR 3.02; 95% confidence interval (CI) 1.51–6.02; p = 0.002). Associations were statistically significant after adjusting for covariates in the penalized multivariable model (adjusted OR 2.06; 95%CI 1.02–4.18; p = 0.043), propensity score adjusted multivariable model (adjusted OR 2.46; 95%CI 1.19–5.07; p = 0.015), and IPW (adjusted OR 2.11; 95%CI 1.28–3.47; p = 0.041). We found that the Syntax score of lesions did not affect the results. Conclusion: MVI-S was associated with a lower incidence of major adverse cardiovascular events within 30 days after discharge.