MULTIVESSEL VERSUS CULPRIT-ONLY PRIMARY PERCUTANEOUS CORONARY INTERVENTION IN PATIENTS WITH MULTIVESSEL DISEASE AND ST-ELEVATION MYOCARDIAL INFARCTION COMPLICATED WITH CARDIOGENIC SHOCK (original) (raw)
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American Heart Journal, 2004
BACKGROUND Recent trials demonstrated a benefit of multivessel percutaneous coronary intervention (PCI) for noninfarct-related artery (non-IRA) stenosis over IRA-only PCI in patients with ST-segment elevation myocardial infarction (STEMI) multivessel disease. However, evidence is limited in patients with cardiogenic shock. OBJECTIVES This study investigated the prognostic impact of multivessel PCI in patients with STEMI multivessel disease presenting with cardiogenic shock, using the nationwide, multicenter, prospective KAMIR-NIH (Korea Acute Myocardial Infarction-National Institutes of Health) registry. METHODS Among 13,104 consecutive patients enrolled in the KAMIR-NIH registry, we selected patients with STEMI with multivessel disease presenting with cardiogenic shock and who underwent primary PCI. Primary outcome was 1-year all-cause death, and secondary outcomes included patient-oriented composite outcome (a composite of all-cause death, any myocardial infarction, and any repeat revascularization) and its individual components. RESULTS A total of 659 patients were treated by multivessel PCI (n ¼ 260) or IRA-only PCI (n ¼ 399) strategy. The risk of all-cause death and non-IRA repeat revascularization was significantly lower in the multivessel PCI group than in the IRA-only PCI group (21.3% vs. 31.7%; hazard ratio: 0.59; 95% confidence interval: 0.43 to 0.82; p ¼ 0.001; and 6.7% vs. 8.2%; hazard ratio: 0.39; 95% confidence interval: 0.17 to 0.90; p ¼ 0.028, respectively). Results were consistent after multivariable regression, propensity-score matching, and inverse probability weighting to adjust for baseline differences. In a multivariable model, multivessel PCI was independently associated with reduced risk of 1-year all-cause death and patient-oriented composite outcome. CONCLUSIONS Of patients with STEMI and multivessel disease with cardiogenic shock, multivessel PCI was associated with a significantly lower risk of all-cause death and non-IRA repeat revascularization. Our data suggest that multivessel PCI for complete revascularization is a reasonable strategy to improve outcomes in patients with STEMI with cardiogenic shock.
The American Journal of Cardiology, 2012
The value of multivessel percutaneous coronary intervention (MV-PCI) in patients with cardiogenic shock (CS) and multivessel disease (MVD) is still unclear because randomized controlled trials are missing. Therefore, we sought to evaluate the impact of MV-PCI on in-hospital outcomes of patients with MVD presenting with CS: 336 patients with acute myocardial infarction complicated by CS and >70% stenoses in >2 major epicardial vessels were included in this analysis of the Euro Heart Survey PCI registry. Patients undergoing MV-PCI (n ؍ 82, 24%) were compared to those with single-vessel PCI (n ؍ 254, 76%). The rate of 3-vessel disease (60% vs 57%, p ؍ 0.63) was similar in the 2 cohorts. Presentation with resuscitation (48 vs 46%, p ؍ 0.76) and ST-segment elevation myocardial infarction (83 vs 87%, p ؍ 0.31) was frequent in patients with MV-PCI and single-vessel PCI. Patients with ventilation were more likely to receive MV-PCI (30% vs 19%, p ؍ 0.05). There was a tendency toward a higher hospital mortality in patients with MV-PCI (48.8% vs 37.4%, p ؍ 0.07). After adjustment for confounding variables, no significant difference for in-hospital mortality (odd ratio [OR] 1.28, 95% confidence interval [CI] 0.72 to 2.28) could be observed between the 2 groups. Age (OR 1.41, 95% CI 1.13 to 1.77), 3-vessel disease (OR 1.78, 95% CI 1.04 to 3.03), ventilation (OR 3.01, 95% CI 1.59 to 5.68), and previous resuscitation (OR 2.55, 95% CI 1.48 to 4.39) were independent predictors of hospital death. In conclusion, MV-PCI is currently used in only 1/4 of patients with CS and MVD. An additional nonculprit PCI was not associated with a survival benefit in these high risk patients. © 2012 Elsevier Inc. All rights reserved. (Am J Cardiol 2012;109:941-946)
Coronary Artery Disease, 2018
Background The safety and efficacy of immediate multivessel coronary intervention (MVI) remain controversial in patients with ST-elevation myocardial infarction (STEMI) and multivessel disease (MVD). This study aimed to investigate the clinical outcomes of immediate MVI compared with culprit-vessel intervention only (CVI-O) in diverse subgroups with STEMI and MVD. Patients and methods We compared immediate MVI (n = 260) and CVI-O (n = 931) regarding 1-year major adverse cardiac event rates for cardiac death, recurrent myocardial infarction (MI), and repeat revascularization in 1191 STEMI patients with MVD using data from the Korea Acute Myocardial Infarction-National Institutes of Health registry (2011-2015). High-risk patients and those who underwent a staged procedure were excluded from the analysis. Furthermore, propensity score matching and stratified subgroup analyses were performed. Results Immediate MVI and CVI-O groups had similar 1-year major adverse cardiac event rates [7.7 vs. 8.9%, hazard ratio (HR): 0.86, 95% confidence interval (CI): 0.50-1.47, log-rank P = 0.5628]. No difference was found between the groups in terms of the 1-year rate of cardiac death (2.9 vs. 1.3%, HR: 2.24, 95% CI: 0.75-6.67) or recurrent MI (2 vs. 1.5%, HR: 1.41, 95% CI: 0.45-4.44). However, repeat revascularization occurred less frequently in the immediate MVI group than in the CVI-O group (2.0 vs. 5.7%, HR: 0.35, 95% CI: 0.13-0.90, logrank P = 0.0142). These findings were found to be consistent across a broad spectrum of subgroups. Conclusion Compared with CVI-O, immediate MVI did not improve 1-year net clinical outcomes in stable STEMI patients with MVD. The only benefit found was a reduced repeat revascularization in immediate MVI.
American Journal of Therapeutics, 2011
Primary percutaneous coronary intervention (PCI) of culprit lesions (CLs) is the standard of care in patients presenting with ST elevation myocardial infarction (STEMI). However, optimal revascularization strategy for significant nonculprit lesions (non-CLs) in the setting of STEMI remains controversial. The importance of defining of such a strategy lies in the fact that approximately 50% of patients with STEMI have multivessel disease (MVD). The aim of this study was to describe characteristics, therapeutic strategies, and 1-year outcomes in a cohort of patients with STEMI and MVD. We retrospectively analyzed a cohort of 63 patients with STEMI and MVD obtained from a 5-year catheterization database. MVD was defined as 7070% stenosis of 702 epicardial coronary arteries. This cohort was followed for a period of 1 year for major adverse cardiac events (MACE was defined as acute coronary syndrome, new onset heart failure, or death) and all-cause mortality. PCI with stent placement was the major therapeutic procedure (87.5%) performed for CLs. Non-CLs did not undergo interventions in a majority of individuals (47.6%), while the remaining patients underwent PCI (29%) and coronary artery bypass graft surgery (22%) for non-CLs. At 1-year followup, prevalence of MACE events and death in the entire cohort were 30% and 15%, respectively. A trend for better outcomes (1-year cumulative MACE events but not mortality) was observed in CL-only intervention cohort compared with non-CL intervention. The PCI and Coronary artery bypass graft surgery cohorts did not show any significant difference in clinical outcomes. In this retrospective cohort of patients with MVD who presented with STEMI, no intervention of noncritical lesions was the prevalent approach, reflecting guideline recommendations. CL-only intervention strategy showed a better clinical outcome than non-CL intervention. Intervention of noncritical lesions therefore did not seem to improve MACEs or all-cause mortality at 1-year of follow-up and might in fact have had a detrimental effect on outcomes.
American Journal of Cardiology, 2015
The optimal management strategy for patients with ST-elevation myocardial infarction (STEMI) and multivessel disease has not been well established. In the current cohort study, we sought to examine the safety and efficacy of in-hospital staged PCI for STEMI patients with multivessel disease. We identified all patients with STEMI referred for primary PCI who were found to have multivessel disease (stenosis ≥50% in non-culprit vessel), and compared clinical outcomes in relation to the management strategy, staged versus culprit-only PCI, for non-culprit vessel disease. The primary outcome was mortality at 180 days, and secondary outcomes included mortality during the index hospitalization and at 30 days, myocardial infarction, stent thrombosis, stroke, and bleeding. Amongst 1038 STEMI patients meeting inclusion criteria, 259 (25%) underwent staged PCI and 779 (75%) culprit-only PCI during the index admission. Mortality at 180 days was 0.8% in patients with staged PCI and 5.0% in patients with culpritonly PCI (p=0.003). The association between staged PCI and reduced mortality persisted after adjusting for baseline differences in patient characteristics and angiographic variables between the two cohorts (OR 0.2, 95%CI 0.04-0.77, p=0.02). The rates of in-hospital reinfarction in the staged and culprit-only PCI cohorts were 0.8% vs 1.3% (p=0.50), respectively; stent thrombosis 0.8% vs 1.3% (p=0.50); and stroke 0.4% vs 1.3% (p=0.31). There were no in-hospital adverse events related to acute occlusion of a non-culprit vessel in either cohort. Staged PCI during index admission is a safe and effective revascularization strategy for STEMI patients with multivessel disease.
Circulation-cardiovascular Quality and Outcomes, 2014
I n patients presenting with ST-segment-elevation myocardial infarction (STEMI), primary percutaneous coronary intervention (PPCI) is associated with improved clinical outcomes. 1,2 It is estimated that 40% to 65% of patients presenting with STEMI have bystander disease seen at the time of PPCI. 3,4 In this setting, the presence of multivessel disease Background-It is estimated that up to two thirds of patients presenting with ST-segment-elevation myocardial infarction have multivessel disease. The optimal strategy for treating nonculprit disease is currently under debate. This study provides a real-world analysis comparing a strategy of culprit-vessel intervention (CVI) versus multivessel intervention at the time of primary percutaneous coronary intervention in patients with ST-segment-elevation myocardial infarction. Methods and Results-We compared CVI versus multivessel intervention in 3984 patients with multivessel disease undergoing primary percutaneous coronary intervention between 2004 and 2011 at all 8 tertiary cardiac centers in London. Multivariable-adjusted models were built to determine independent predictors for in-hospital major adverse cardiovascular events (MACEs) and all-cause mortality at 1 year. To reduce confounding and bias, propensity score methods were used. CVI was associated with reduced in-hospital MACE (4.6% versus 7.2%; P=0.010) and mortality at 1 year (7.4% versus 10.1%; P=0.031). CVI was an independent predictor for reduced in-hospital MACE (odds ratio, 0.49; 95% confidence interval [CI], 0.32-0.75; P<0.001) and survival at 1 year (hazard ratio, 0.65; 95% CI, 0.47-0.91; P=0.011) in the complete cohort; and in 2821 patients in propensity-matched cohort (in-hospital MACE: odds ratio, 0.49; 95% CI, 0.32-0.76; P=0.002; and 1-year survival: hazard ratio, 0.64; 95% CI, 0.45-0.90; P=0.010). Inverse probability treatment weighted analyses also confirmed CVI as an independent predictor for reduced in-hospital MACE (odds ratio, 0.38; 95% CI, 0.15-0.96; P=0.040) and survival at 1 year (hazard ratio, 0.44; 95% CI, 0.21-0.93; P=0.033). Conclusions-In this observational analysis of patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention, CVI was associated with increased survival at 1 year. Acknowledging the limitations with observational analyses, our findings support current recommended practice guidelines. (Circ Cardiovasc Qual Outcomes. 2014;7:936-943.
Management of multivessel coronary disease in STEMI patients: A systematic review and meta-analysis
International Journal of Cardiology, 2015
Background: Appropriate management for patients with multivessel coronary disease presenting with ST segment Elevation Myocardial Infarction (STEMI) remains to be defined. Methods and results: Medline and Cochrane Library were searched for randomized controlled trials (RCTs) or observational studies adjusted with multivariate analysis, reporting about STEMI patients with multivessel coronary disease treated with either a culprit only or complete revascularization strategy, excluding patients in cardiogenic shock. Prespecified analysis was performed according to the strategy of complete revascularization, either during the same procedure of primary percutaneous coronary intervention (PCI) or during the index hospitalization. MACE (a composite and mutually exclusive end point of death or myocardial infarction or revascularization) at follow-up of at least one year was the primary end point. 9 studies with 4686 patients compared culprit only versus complete PCI performed during the primary PCI. Rates of MACE did not differ at 90 days (OR 0.70 [0.38, 1.27], I 2 = 0%) or at 1 year (1-2.5) (OR 0.70 [0.47, 1.03], I 2 = 0%). No significant difference was found for the components of the primary outcome, apart from a reduction in repeated revascularization for patients undergoing complete PCI during the STEMI procedure (OR 0.62 [0.39, 0.98], I 2 = 0%). 6 studies (1 RCT) with 5855 patients compared culprit only lesions versus complete PCI performed during index hospitalization. 90 day risk of MACE did not differ nor 1 year (1-2.5) MACE (OR 0.86 [0.62, 1.08], I 2 = 0%), with a similar reduction in repeated revascularization (0.60 [0.40, 0.90], I 2 = 0%). Conclusions: Complete revascularization performed during primary PCI or index hospitalizations for patients presenting with STEMI appears safe at short term follow-up and offers a reduction in repeated revascularization at one year.
Journal of the American College of Cardiology, 2011
The purposes of this study were to investigate whether, in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD), percutaneous coronary intervention (PCI) should be confined to the culprit or also nonculprit vessels and, when performing PCI for nonculprit vessels, whether it should take place during primary PCI or staged procedures. Background A significant percentage of STEMI patients have MVD. However, the best PCI strategy for nonculprit vessel lesions is unknown. Methods Pairwise and network meta-analyses were performed on 3 PCI strategies for MVD in STEMI patients: 1) culprit vessel only PCI strategy (culprit PCI), defined as PCI confined to culprit vessel lesions only; 2) multivessel PCI strategy (MV-PCI), defined as PCI of culprit vessel as well as Ն1 nonculprit vessel lesions; and 3) staged PCI strategy (staged PCI), defined as PCI confined to culprit vessel, after which Ն1 nonculprit vessel lesions are treated during staged procedures. Prospective and retrospective studies were included when research subjects were patients with STEMI and MVD undergoing PCI. The primary endpoint was short-term mortality. Results Four prospective and 14 retrospective studies involving 40,280 patients were included. Pairwise meta-analyses demonstrated that staged PCI was associated with lower short-and long-term mortality as compared with culprit PCI and MV-PCI and that MV-PCI was associated with highest mortality rates at both short-and long-term followup. In network analyses, staged PCI was also consistently associated with lower mortality. Conclusions This meta-analysis supports current guidelines discouraging performance of multivessel primary PCI for STEMI. When significant nonculprit vessel lesions are suitable for PCI, they should only be treated during staged procedures.
Impact of multivessel disease on infarct size among STEMI patients undergoing primary angioplasty
Atherosclerosis, 2014
Background: Although primary angioplasty achieves Thrombolysis In Myocardial Infarction (TIMI) 3 flow in most patients with ST-elevation myocardial infarction, epicardial recanalization does not guarantee optimal perfusion in a large proportion of patients. Multivessel disease has been demonstrated to be associated with impaired survival, however its impact on infarct size has not been largely investigated, that therefore is the aim of the current study. Methods: Our population is represented by 827 STEMI patients undergoing primary PCI. Infarct size was evaluated at 30 days by technetium-99m-sestamibi. Results: Multivessel disease was observed in 343 patients (41.5%). It was associated with older age (65 [57e74] vs 63 [53e71], p < 0.001), higher rate of previous MI (6.4% vs 2.5%, p ¼ 0.005), longer ischemia time evaluated as continuous variable (210 [155e280] min vs 196 [145e270] min, p ¼ 0.065) or percentage of patients with ischemia time >3 h (63.7% vs 56.4%, p ¼ 0.038), and a trend in more cardiogenic shock (5.5% vs 2.9%, p ¼ 0.055). Patients with multivessel disease received more often Abciximab (92.1% vs 88.4%, p < 0.001), Intra-aortic balloon pump (6.4% vs 1.9%, p < 0.001). No differences were observed in other clinical or angiographic characteristics. In particular, multivessel disease did not affect the rate of postprocedural TIMI 3 flow (90.9% vs 93.4%, p ¼ 0.18) and ST-segment resolution (52.4% vs 54.9%, p ¼ 0.48). Multivessel disease did not affect infarct size (12.7% [4.5%e24.9%] vs 12.3% [4%e24.1%], p ¼ 0.58). Similar results were observed in subanalyses without any significant interaction for each variable (anterior infarct location (p int ¼ 0.23), gender (p int ¼ 0.9), age (p int ¼ 0.7), diabetes (p int ¼ 0.15)). The absence of any impact of multivessel disease on infarct size was confirmed when the analysis was conducted according to the percentage of patients with infarct size above the median, even after correction for baseline characteristics, such as age, previous MI, ischemia time, use of Gp IIbeIIIa inhibitors, cardiogenic shock, ischemia time (OR [95% CI] ¼ 1.09 [0.82e1.45], p ¼ 0.58). Conclusions: This study shows that among STEMI patients undergoing primary PCI multivessel disease does not affect infarct size.