Complete versus culprit-only revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease: a meta-analysis of randomized trials

Revascularization strategies in STEMI and multivessel disease

INTRODUCTION

The main treatment for ST-elevation myocardial infarction (STEMI) is the re-establishment of the coronary flow of infarct-related arteries. However, 50% of cases present multivessel disease (MVD), negatively affecting mortality. Complete revascularization (CR) is currently advocated since it reduces major adverse cardiovascular events (MACE).

OBJECTIVE

Evaluation of the adopted revascularization strategy and its prognostic value in a Portuguese cohort of STEMI patients with MVD.

MATERIAL AND METHODS

Retrospective analysis of patients admitted with STEMI included in the Portuguese Registry of Acute Coronary Syndromes between 2010 and 2019. Patients were divided in two groups regarding revascularization strategy (complete versus incomplete) and compared. Independent predictors of a composite of all-cause mortality and rehospitalization for cardiovascular causes were assessed by multivariate logistic regression.

RESULTS

A total of 3500 patients were included. A CR strategy was performed in 21.8% of patients, who were younger and healthier. They also presented more hemodynamically stable and had less kidney dysfunction and anaemia. Their coronary anatomy was less complex, with a higher prevalence of 2-vessel and a lower proportion of chronic occlusions. In-hospital and 1-year adverse events were less frequent between patients with CR.

CONCLUSION

In hemodynamically stable STEMI patients, CR substantially reduced in-hospital and 1-year all-cause mortality and MACE.

CHA2DS2-VASc score predicts the slow flow/no-reflow phenomenon in ST-segment elevation myocardial infarction patients with multivessel disease undergoing primary percutaneous coronary intervention

ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease (MVD) have a higher incidence of slow-flow/no-reflow (SF-NR) phenomenon during primary percutaneous coronary intervention (PPCI) than those with single vessel disease. Currently, no effective tools exist to predict the risk of SF-NR in this population. The present study aimed to evaluate whether CHA2DS2-VASc score can be used as a simple tool to predict this risk.This study consecutively included STEMI patients hospitalized in Beijing Anzhen Hospital from January 2005 to January 2015. Among these patients, 1032 patients with MVD were finally enrolled. Patients were divided into SF-NR (+) group and SF-NR (-) group according to whether SF-NR occurred during PPCI. SF-NR was defined as the thrombolysis in myocardial infarction (TIMI) grade ≤2.There were 134 patients (13%) in the SF-NR (+) group. Compared with the SF-NR (-) group, patients in the SF-NR (+) group are elder, with lower left ventricular ejection fraction and higher CHA2DS2-VASc score. Multiple logistic regression analysis indicated that CHA2DS2-VASc score ≥3 (odds ratio [OR], 2.148; 95% confidence interval [CI], 1.389-3.320; P = .001), current smoking (OR, 1.814; 95% CI, 1.19-2.764; P = .006), atrial fibrillation (OR, 2.892; 95% CI, 1.138-7.350; P = .03), complete revascularization (OR, 2.307; 95% CI, 1.202-4.429; P = .01), and total length of stents ≥40 mm (OR, 1.482; 95% CI, 1.011-2.172; P = .04) were independent risk factors of SF-NR. The incidence of SF-NR in patients with CHA2DS2-VASc score ≥3 was 1.7 times higher than that in patients with CHA2DS2-VASc score <3. Additionally, patients with CHA2DS2-VASc score ≥3 plus ≥2 risk factors have 3 times higher incidence of SF-NR than those with CHA2DS2-VASc score ≥3 plus 0 to 1 risk factor.CHA2DS2-VASc score ≥3 can be used as a simple and sensitive indicator to predict SF-NR phenomenon and guide the PPCI strategy in STEMI patients with MVD.

Long-Term Follow-Up of Contrast-Induced Acute Kidney Injury: A Study from a Developing Country

Introduction

Contrast-induced acute kidney injury (CI-AKI) is a worldwide known complication related to the use of contrast media with either imaging or angiography; it carries its own complications and effect on both morbidity and mortality; early identification of patients at risk and addressing modifiable risk factors may help reducing risk for this disease and its complications.

Methods

This was a prospective observational study, where all patients admitted for cardiac catheterization between June 2015 and January 2016 were evaluated for CI-AKI. There were two study groups: contrast-induced acute kidney injury (CI-AKI) group, and noncontrast-induced acute kidney injury (non-CI-AKI) group.

Results

Patients (n = 202) were included and followed up for 4 years. Death and development of chronic kidney disease (CKD) need for another revascularization were the end points. The incidence of CI-AKI was 14.8%.In univariate analysis, age (P = 0.016) and serum albumin at admission (P = 0.001) were statistically significant predictors of overall death. Age (P = 0.002), HTN (P = 0.002), DM (P = 0.02), and the use of diuretics (P = 0.001) had a statistically significant impact on eGFR. The rate of recatheterization was not statistically significant between the two groups (61 (35.5%) for the non-CI-AKI vs. 12 (40%) for the other group; P = 0.63). Some inflammatory markers (NGAL P = 0.06, IL-19 P = 0.08) and serum albumin at admission P = 0.07 had a trend toward a statistically significant impact on recatheterization. Death (P = 0.66) and need for recatheterization (P = 0.63) were not statistically different between the 2 groups, while the rate of eGFR decline in for the CI-AKI was significant (P = 0.004).

Conclusion

CI-AKI is a common complication post percutaneous catheterization (PCI), which may increase the risk for CKD, but not death or the need for recatheterization. Preventive measures must be taken early to decrease the morbidity.

Percutaneous Versus Surgical Revascularization for Acute Myocardial Infarction

INTRODUCTION

Acute myocardial infarction (AMI) is a common medical condition in our clinical practice that should be treated with appropriate revascularization in a timely manner. Percutaneous revascularization (PR) has been the first-line treatment option when feasible. Limited data is available comparing PR to surgical revascularization (SR) in the AMI setting.

METHODS

Study population was extracted from the 2016 Nationwide Readmissions Data using International Classification of Diseases, tenth edition, clinical modifications/procedure coding system codes for AMI, PR, SR, and procedural complications. Study endpoints included in-hospital all-cause mortality, length of index hospital stay (LOS), stroke, acute kidney injury, bleeding, need for blood transfusion, acute respiratory failure, and total hospital charges.

RESULTS

The study identified 45,539 discharges with a principal admission diagnosis of AMI (38.7% ST elevation and 61.3% non-ST elevation) who had either PR or SR as a principal procedure (79.1% PR versus 20.9% SR). Single vessel revascularization was performed in 67.8% (93.1% had PR versus 6.9% had SR, p < 0.01). Multivessel revascularization was performed in 32.2% (64.8% had PR versus 35.2% had SR, p < 0.01). 83% of SR was in the setting of non-ST elevation AMI (NSTEMI). In comparison to SR, PR was associated with higher in-hospital all-cause mortality (3.7% versus 2.2%, p < 0.01), shorter LOS (4.3 versus 11.6 days, p < 0.01), and lower incidence of post-procedural stroke (1.0% versus 1.8%, p < 0.01), acute kidney injury (14.9% versus 24.8%, p < 0.01), bleeding (4.3% versus 47.1%, p < 0.01), need for blood transfusion (2.9% versus 18.5%, p < 0.01), acute respiratory failure (10.7% versus 19.8%, p < 0.01), and total hospital charges (120,590$ versus 229,917$, p < 0.01). These results persist after adjustment for baseline characteristics. In a subgroup analysis, SR mortality benefit persisted in patients who had multivessel revascularization (in both ST and non-ST elevation AMI), but not in single vessel revascularization.

CONCLUSIONS

In patients presented with AMI, PR was associated with higher in-hospital all-cause mortality but lower morbidity, shorter LOS, and lower total hospital charges than SR. However, the mortality benefit of SR was seen in multivessel revascularization only, and not in single vessel revascularization.

Meta-Analysis of Optimal Revascularization Strategy for Patients With ST-Segment Elevation Myocardial Infarction and Multi-Vessel Coronary Artery Disease

Several clinical trials have shown that complete revascularization (CR) lowers the risks of revascularization and nonfatal myocardial infarction (MI) in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease compared with infarct-related artery-only revascularization (IRA-OR). However, individual trials have been underpowered for hard outcomes such as cardiovascular (CV) mortality. Therefore, we conducted an updated meta-analysis representing the largest sample size to date inclusive of contemporary studies comparing CR versus IRA-OR. Pooled risk ratios (RRs) were calculated using random effects model. Data from 11 RCTs involving 7,343 patients showed that compared with IRA-OR, CR was associated with lower CV mortality (RR 0.75; 95% confidence interval [CI] 0.57 to 0.99; p = 0.04), MI (RR 0.70; 95% CI 0.53 to 0.93), and recurrent revascularization (RR 0.38; 95% CI 0.27 to 0.54), but similar all-cause mortality (RR 0.85; 95% CI 0.70 to 1.05). In conclusion, in patients with STEMI and multivessel coronary artery disease, compared with IRA-OR, CR was associated with lower risk for CV mortality, MI, and recurrent revascularization, suggesting that CR should be the standard of care for STEMI patients.

Multivessel vs. culprit-lesion only percutaneous coronary intervention in ST-elevation myocardial infarction

The optimal treatment of non-infarct-related coronary arteries in patients presenting with ST-elevation myocardial infarction (STEMI) has been a subject of debate for many years. Earlier medium-sized randomized controlled trials reported a benefit of multivessel percutaneous coronary intervention (PCI) primarily due to a reduction of subsequent revascularizations. Recently, the well-powered COMPLETE trial showed a reduction in the composite endpoint of cardiovascular mortality and myocardial reinfarction through complete revascularization. The present review summarizes the current evidence regarding revascularization strategies in STEMI patients.

Should fractional flow reserve follow angiographic visual inspection to guide preventive percutaneous coronary intervention in ST-elevation myocardial infarction?

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.

Meta-Analysis Comparing Complete Versus Infarct-Related Artery Revascularization in Patients With ST-Elevation Myocardial Infarction and Multivessel Coronary Disease

A strategy of complete revascularization (CR) versus infarct-related artery revascularization (IRA) in patients with ST-elevation myocardial infarction (STEMI) continues to be a subject of debate. We performed an updated meta-analysis to compare the 2 strategies. Outcomes of interest included major adverse cardiovascular events (MACE), cardiovascular mortality, all-cause mortality, stroke, repeat revascularization, myocardial infarction, and contrast-induced nephropathy. Ten randomized trials including 7,423 patients (CR = 3,574 and IRA = 3,849), with a follow-up of 2.0 ± 0.8 years were included. There was a significant reduction in MACE with CR versus IRA (10.7% vs 18.6%, relative risk [RR] 0.64, 95% confidence interval [CI] 0.51 to 0.81, p = 0.002, I² = 66%), with higher risk reduction with immediate versus stages revascularization (RR 0.40, 95% CI 0.32 to 0.5 vs RR 0.69, 95% CI 0.54 to 0.89, P-interaction = 0.002). Complete revascularization was associated with lower rates of repeat revascularization (4.0% vs 11.7%, RR 0.44, 95% CI 0.28 to 0.70, p <0.0001, I² = 81%), and a nonsignificant trend toward lower cardiovascular mortality (2.8% vs 3.7%, RR 0.78, 95% CI 0.60 to 1.03, p = 0.08, I² = 0%). However, there was no difference between the 2 strategies in all-cause mortality (4.6% vs 4.8%, RR 0.90, 95% CI 0.73 to 1.12, p = 0.36, I² = 0%), myocardial infarction (5.2% vs 6.5%, RR 0.73, 95% CI, 0.58 to 1.08, p = 0.08, I² = 30%), stroke (1.5% vs 1.2%, RR 1.14, 95% CI 0.56 to 2.29, p = 0.33, I² = 14%), or contrast-induced nephropathy (1.6% vs 1.2%, RR 1.35, 95% CI 0.85 to 2.15, p = 0.78, I² = 0%). In conclusion, CR in patients with STEMI is associated with significant reduction in MACE compared with IRA. This reduction is derived mainly by the low rates of repeat revascularization in the CR group.