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• Justification for complete revascularisation at the time of primary angioplasty? Not yet!
  Nick West
  Published on: 23 November 2015
• is it reasonable to separate the culprit-vessel only revascularization as a group from the culprit-vessel revascularization?
  Yu Cheng Chen
  Published on: 23 November 2015
• To the Editor
  Jan-Henk E. Dambrink
  Published on: 23 November 2015

• Published on: 23 November 2015

  Justification for complete revascularisation at the time of primary angioplasty? Not yet!

  • Nick West
  • Other Contributors:
    • Francis R. Joshi, Liam McCormick

  We read with great interest the article by Politi et al. (1) on revascularisation of patients presenting with ST-elevation myocardial infarction (STEMI) in the context of multivessel coronary disease, and its accompanying Editorial. Whilst the data are interesting and hypothesis- generating, they fall short of demanding any change in current practice owing to a potential flaw in the study design and in the findings as pre...

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  We read with great interest the article by Politi et al. (1) on revascularisation of patients presenting with ST-elevation myocardial infarction (STEMI) in the context of multivessel coronary disease, and its accompanying Editorial. Whilst the data are interesting and hypothesis- generating, they fall short of demanding any change in current practice owing to a potential flaw in the study design and in the findings as presented that makes it difficult to fully agree with the authors' conclusions.

  Firstly, no explanation is given for the MACE detriment seen in the culprit-only revascularisation (COR) group; we would agree with previous comments regarding the reasons for repeat rehospitalisation and repeat revascularisation, that both require further clarification to understand their importance. However, it is the high inhospital mortality rate in the COR group compared with the staged revascularisation (SR) group that is most perplexing: both groups would have been expected to have a similar inhospital course given the same initial PCI strategy, with the SR group perhaps being expected to perform better than COR at medium- or long-term follow-up. This, along with the imbalance in patient numbers between groups, perhaps suggests that the results are presented by treatment received rather than by intention-to-treat (ie. patient randomised to SR dies in hospital after initial PCI and is counted in COR group), thereby introducing a bias that may render the results uninterpretable.

  Secondly, and perhaps more importantly, the study by Qarawani et al. (2) used to inform the power calculation to determine the sample size for this study is not only a nonrandomised study with a huge imbalance in the numbers within its 2 arms, but crucially is also an outlier in terms of the difference in MACE rates between COR and CR during primary angioplasty: inhospital MACE rates were 52% and 16.7% respectively, compared with far more modest differences of 0 vs. 3.8% observed in the study by Di Mario et al. (3) and 6.3 vs. 7.4% in the study by Ijsselmuiden et al. (4). In this latter study, a randomised comparison with a similar number of patients in the COR and CR arms as that of Politi et al. (1), MACE rates at 1 year were still not significantly different between the two arms (32.4 vs. 26.9%) in stark contrast to the findings described here. Granted, these studies were performed when primary angioplasty techniques were not as advanced as today in terms of device and pharmacological developments, but even so it is difficult to justify the retrospective application of a power calculation from a study that is more contemporary (Qarawani et al. (2) published their findings in 2008, the year after patient recruitment for the study of Politi et al (1) had finished) simply to provide the statistical power to generate a significant p value.

  For the moment, we believe that in primary angioplasty for STEMI in the absence of cardiogenic shock, there is not enough evidence to support a change from the strategy of culprit-only revascularisation with a staged approach to non-culprit lesions. Clearly we agree with the authors that further research, likely in the form of a large multicentre randomised trial, is needed to determine the optimal therapy for these patients.

  References

  1. A randomised trial of target-vessel versus multi-vessel revascularisation in ST-elevation myocardial infarction: major adverse cardiac events during long-term follow-up. Politi L, Sgura F, Rossi R et al. Heart 2010; 96: 662-667.

  2. Culprit only versus complete coronary revascularization during primary PCI. Qarawani D, Nahir M, Abboud M et al. Int J Cardiol 2008; 123: 288-292.

  3. Single vs. multivessel treatment during primary angioplasty: results of the multicentre randomised HEpacoat for culprit or multivessel stenting for Acute Myocardial Infarction (HELP-AMI) study. Di Mario C, Mara S, Flavio A et al. Int J Cardiovasc Intervent 2004; 6: 128-133.

  4. Complete versus culprit vessel percutaneous coronary intervention in multivessel disease: A randomized comparison. Ijsselmuiden AJJ, Ezechiels JP, Westendorp ICD et al. Am Heart J 2004; 148: 467-474.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
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• Published on: 23 November 2015

  is it reasonable to separate the culprit-vessel only revascularization as a group from the culprit-vessel revascularization?

  • Yu Cheng Chen, medical doctor
  • Other Contributors:
    • Cong Lu

  We read with interest the work "A randomised trial of target-vessel versus multi-vessel revascularisation in ST-elevation myocardial infarction: major adverse cardiac events during long-term follow-up"by Luigi Politi. According to the conclusion of the article, culprit vessel- only angioplasty was associated with the highest rate of long-term MACE compared with multivessel treatment including simultaneous revascularizati...

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  We read with interest the work "A randomised trial of target-vessel versus multi-vessel revascularisation in ST-elevation myocardial infarction: major adverse cardiac events during long-term follow-up"by Luigi Politi. According to the conclusion of the article, culprit vessel- only angioplasty was associated with the highest rate of long-term MACE compared with multivessel treatment including simultaneous revascularization and staged revascularization[1].

  This is the first prospective study in which the culprit-only revascularisation was separated as a isolated group(excluded the staged revascularization) while previous studies divided patients into two groups[2][3]. Is this classification reasonable?

  According to the ACC/AHA recommendation[4], the culprit vessel should be treated in the primary procedure, and staged PCI can be performed in an elective procedure for the STEMI patients with multivessel disease. But in this study, staged PCI had not been considered in the COR group for 2.5 years.So the higher incidence of re-PCI and re-hospitalization was inevitable. The investigators aslo admitted that the incidence of repeat revascularisation and re-hospitalisation was significantly higher only in the COR group, whereas there was no significant difference in other outcomes among the three groups. Under the circumstances, the higher rate of long-term MACE in COR group is a really convinced conclusion?

  references [1] Luigi Politi, Fabio Sgura, Rosario Rossi, et al.A randomised trial of target-vessel versus multi-vessel revascularisation in ST-elevation myocardial infarction: major adverse cardiac events during long-term follow-up.heart 2010;96:662-667. [2] Di Mario C, Mara S, Flavio A, et al. Single vs multivessel treatment during primary angioplasty: results of the multicentre randomised HEpacoat for cuLPrit or multivessel stenting for Acute Myocardial Infarction ((HELP AMI) Study. Int J Cardiovasc Intervent 2004;6:128-133. [3] Khattab AA, Abdel-Wahab M, Rother C, et al. Multi-vessel stenting during primary percutaneous coronary intervention for acute myocardial infarction: A single- center experience.Clin Res Cardiol 2008;97:32-38. [4] Antman EM, Hand M, Armstrong PW, et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2008;51:210-47.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
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• Published on: 23 November 2015

  To the Editor

  • Jan-Henk E. Dambrink
  • Other Contributors:
    • Arnoud W.J. van 't Hof

  With great interest we have read the article by Politi et al(1) on revascularisation of patients with ST-elevation myocardial infarction and multivessel disease. The authors are to be complimented with the largest randomised trial on this subject, with the longest follow-up.

  However, we question whether this study is the 'justification for complete revascularisation at the time of primary angioplasty', as the p...

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  With great interest we have read the article by Politi et al(1) on revascularisation of patients with ST-elevation myocardial infarction and multivessel disease. The authors are to be complimented with the largest randomised trial on this subject, with the longest follow-up.

  However, we question whether this study is the 'justification for complete revascularisation at the time of primary angioplasty', as the paper is labeled by the accompanying Editorial. Apart from the considerable imbalance in patient numbers, which remains unexplained, there are several other major concerns.

  First, there is no mentioning of routine non-invasive testing for ischemia after discharge in the COR group, as is currently advocated by the guidelines(2). Thus, it is not clear if the additional PCI procedures in the COR group were unexpected events or a result of planned non- invasive testing. All these events were considered MACEs in the COR group, while planned revascularisations in the SR group were not.

  Second, testing for ischemia is relevant since 40% of non-culprit lesions do not produce ischemia, as we demonstrated in a recent randomised trial of FFR-guided early (7.5 days) additional revascularisation versus culprit-only revascularisation(3). Also, we found that after 6 months death and MI had occurred only in the early treatment group. This underlines that early additional treatment is probably not without risk, while benefit is not to be expected in a considerable number of patients.

  Third, the importance of complete revascularisation is emphasized in the discussion, but it is not clear in how many patients of the CR or SR group this was actually achieved. Since more complex lesions are to be expected in a population with multivessel disease, in which for instance about 30% of the patients have a CTO, this is a relevant question. It has been suggested that the presence of a CTO is the only independent factor that determines the additional risk in patients with multivessel disease(4).

  For now, it seems that staged PCI of non-culprit lesions guided by ischemia testing is still the most reasonable treatment strategy for patients with multivessel disease and STEMI. We agree with the authors that clearly more research is needed to define the optimal treatment in these patients.

  References

  1. A randomised trial of target-vessel versus multi-vessel revascularisation in ST-elevation myocardial infarction: major adverse cardiac events during long-term follow-up. Politi L, Sgura F, Rossi R, et al. Heart 2010 96: 662-667.

  2. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology. Van de Werf F, Bax J, Betriu A, et al. Eur Heart J 2008 Dec;29(23):2909-45.

  3. Non-culprit lesions detected during primary PCI: treat invasively or follow the guidelines? Dambrink JHE, Debrauwere JP, van 't Hof AWJ, et al. Eurointervention 2010; 5:968-975.

  4. Impact of multivessel coronary disease on long-term mortality in patients with ST-elevation myocardial infarction is due to the presence of a chronic total occlusion. Van der Schaaf RJ, Vis MM, Sjauw KD, et al. Am J Cardiol 2006;98:1165-1169.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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