Multivessel percutaneous coronary intervention in patients with multivessel disease and acute myocardial infarction

doi:10.1016/j.ahj.2004.03.051

American Heart Journal

Volume 148, Issue 3, September 2004, Pages 493-500

https://doi.org/10.1016/j.ahj.2004.03.051 Get rights and content

Abstract

Background

The optimal percutaneous interventional strategy for dealing with significant non-culprit lesions in patients with multivessel disease (MVD) with acute myocardial infarction (AMI) at presentation remains controversial.

Methods

A total of 820 patients treated with primary angioplasty for AMI between 1998 and 2002 were classified in groups of patients with single vessel disease (SVD) or MVD (≥70% stenosis of ≥2 coronary arteries). Patients with MVD were subdivided in 3 groups on the basis of the revascularization strategy: 1) patients undergoing percutaneous coronary intervention (PCI) of the infarct-related artery (IRA) only; 2) patients undergoing PCI of both the IRA and non-IRA(s) during the initial procedure; and 3) patients undergoing PCI of the IRA followed by staged, in-hospital PCI of the non-IRA(s). Procedural, 30-day, and 1-year outcomes are reported.

Results

At 1 year, compared with patients with SVD, patients with MVD had a higher incidence of re-infarction (5.9% vs 1.6%, P = .003), revascularization (18% vs 9.6%, P <.001), mortality (12% vs 3.2%, P <.001), and major adverse cardiac events (MACEs; 31% vs 13%, P <.001). In patients with MVD, compared with PCI restricted to the IRA only, multivessel PCI was associated with higher rates of re-infarction (13.0% vs 2.8%, P <.001), revascularization (25% vs 15%, P = .007), and MACEs (40% vs 28%, P = .006). Multivessel PCI was an independent predictor of MACEs at 1 year (odds ratio = 1.67, P = .01).

Conclusions

These data suggest that in patients with MVD, PCI should be directed at the IRA only, with decisions about PCI of non-culprit lesions guided by objective evidence of residual ischemia at late follow-up. Further studies are needed to confirm these findings.

Section snippets

Study patients

Between 1998 and 2002, 820 patients with AMI were treated with primary PCI. Patients were stratified according to the presence or absence of MVD, which was defined as ≥70% stenosis of ≥2 epicardial coronary arteries or their major branches. Patients with MVD were further classified according to the strategy used for revascularization. Patients in the IRA-only group had only the infarct-related vessel treated, whereas patients in the multivessel PCI group had both the infarct-related and

Results

From January 1998 to January 2002, 820 consecutive patients meeting the entry criteria for this study underwent primary coronary angioplasty for AMI at our institution. Of these patients, 314 (38%) had single-vessel disease (SVD) and 506 (62%) had MVD. Of the patients with MVD, 354 underwent PCI restricted to the IRA only, whereas 152 underwent multivessel PCI, either during the same procedure (N = 26) or in a staged fashion during the index hospitalization (N = 126) (Figure 2).

Discussion

MVD occurs in between 40% and 65% of patients with AMI at presentation1, 2, 3 and confers an increased risk of morbidity and mortality after reperfusion therapy.1, 4, 5 In the setting of AMI, percutaneous revascularization of the culprit lesion is efficacious;6, 7, 8 however, treatment of non-culprit lesions in patients with MVD remains controversial. This study demonstrates that in patients with MVD and AMI, multivessel PCI is technically feasible, but is associated with higher post-procedural

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Complete revascularization of the culprit and all significant nonculprit lesions in patients with non–ST-segment elevation acute coronary syndrome (NSTE-ACS) and multivessel disease (MVD) reduces major adverse cardiac events, but optimal timing of revascularization remains unclear.
This study aims to compare immediate complete revascularization (ICR) and staged complete revascularization (SCR) in patients presenting with NSTE-ACS and MVD.
This prespecified substudy of the BIOVASC (Percutaneous Complete Revascularization Strategies Using Sirolimus Eluting Biodegradable Polymer Coated Stents in Patients Presenting With Acute Coronary Syndrome and Multivessel Disease) trial included patients with NSTE-ACS and MVD. Risk differences of the primary composite outcome of all-cause mortality, myocardial infarction (MI), unplanned ischemia-driven revascularization (UIDR), or cerebrovascular events and its individual components were compared between ICR and SCR at 1 year.
The BIOVASC trial enrolled 1,525 patients; 917 patients presented with NSTE-ACS, of whom 459 were allocated to ICR and 458 to SCR. Incidences of the primary composite outcome were similar in the 2 groups (7.9% vs 10.1%; risk difference 2.2%; 95% CI: −1.5 to 6.0; P = 0.15). ICR was associated with a significant reduction of MIs (2.0% vs 5.3%; risk difference 3.3%; 95% CI: 0.9 to 5.7; P = 0.006), which was maintained after exclusion of procedure-related MIs occurring during the index or staged procedure (2.0% vs 4.4%; risk difference 2.4%; 95% CI: 0.1 to 4.7; P = 0.032). UIDRs were also reduced in the ICR group (4.2% vs 7.8%; risk difference 3.5%; 95% CI: 0.4 to 6.6; P = 0.018).
ICR is safe in patients with NSTE-ACS and MVD and was associated with a reduction in MIs and UIDRs at 1 year.
Long-term clinical outcomes in patients with non-ST-segment Elevation Acute Coronary Syndrome and ST-segment elevation myocardial infarction with thrombolysis in myocardial infarction 0 flow
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Thrombolysis in Myocardial Infarction (TIMI) 0 flow often characterizes ST-segment Elevation Myocardial Infarction (STEMI) patients, but may also feature in non-ST-segment Elevation Acute Coronary Syndrome (NSTE-ACS). Since recanalization usually occurs later in NSTE-ACS patients, the aim of this study was to assess whether patients presenting with NSTE-ACS and TIMI 0 flow have worse clinical outcomes as compared to patients presenting with STEMI and TIMI 0 flow.
A single-center retrospective cohort study was conducted with patients treated for NSTE-ACS and STEMI with TIMI 0 flow at diagnostic angiogram between January 2015 and December 2019. The two patient groups were 1:1 matched using a propensity score logistic regression model. The primary outcome was Major Adverse Cardiac Events (MACE), a composite of all-cause mortality, any myocardial infarction, coronary artery bypass graft, urgent target vessel revascularization or stroke during long term follow-up.
The total population consisted of 1255 ACS patients, of which 249 NSTE-ACS and 1006 STEMI patients. After propensity score matching, 234 NSTE-ACS patients were matched with 234 STEMI patients. In this matched population, the mean age was 62.6 (±12.4) years and 75.2 % of the patients was male. The median follow-up time was 3.2 years. MACE rates during follow-up were similar between the two matched groups (HR = 0.84 [95 % CI 0.60 – 1.12] with p = 0.33) with cumulative event-free survival of 63.3 % in the NSTE-ACS group vs 59.3 % in the STEMI group at 6 year follow-up.
In this retrospective study, a culprit lesion with TIMI 0 flow has similar clinical outcome in NSTE-ACS and STEMI patients. Further research is warranted to determine optimal the timing of PCI in NSTE-ACS patients with TIMI 0 flow.
Prevalence, Predictors, and Outcomes of Patients With ST-Elevation Myocardial Infarction and Angiographically Significant Coronary Artery Disease of Non–Infarct-Related Artery
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Patients with ST-elevation myocardial infarction (STEMI) can present with angiographically significant coronary artery disease (CAD) of non–infarct-related artery (IRA) or with IRA-only CAD. This study aimed to evaluate the prevalence, predictors, and outcome of patients with STEMI and angiographically significant CAD of non-IRA. All consecutive patients with STEMI who underwent primary percutaneous coronary intervention between 2000 and 2020 were included. Angiographically significant CAD was defined as >50% stenosis of the left main coronary artery and/or >90% stenosis for all other coronary arteries. A total of 2,663 patients had IRA-only CAD (80.2%) and 657 had angiographically significant non-IRA CAD (19.8%). Independent predictors for non-IRA CAD were male gender (odds ratio [OR] 1.34, 95% confidence interval [CI] 1.05 to 1.70, p = 0.021), age >50 years (OR 1.45, 95% CI 1.11 to 1.91, p = 0.007), and diabetes mellitus (OR 1.56, 95% CI 1.29 to 1.9, p <0.001), whereas smoking (OR 0.83, 95% CI 0.68 to 0.99, p = 0.004) and family history of CAD (OR 0.78, 95% CI 0.62 to 0.98, p = 0.032) were found to be negatively associated with non-IRA CAD. In-hospital 30-day and 1- and 5-year all-cause mortality were higher in patients with non-IRA CAD compared with IRA-only CAD (5.8% vs 2.5%, 8.5% vs 3.3%, 18.4% vs 7.6% and 36.3% vs 20.3%, respectively; p for all <0.001). In conclusion, 20% of patients with STEMI had angiographically significant non-IRA CAD. Older age, male gender, and diabetes mellitus were independent predictors for non-IRA CAD, whereas smoking and family history of CAD predicted IRA-only CAD. The presence of non-IRA CAD was associated with higher short- and long-term all-cause mortality rates.
Immediate Versus Staged Multivessel PCI Strategies in Patients with ST-Segment Elevation Myocardial Infarction and Multivessel Disease: A Systematic Review and Meta-Analysis
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Recent guidelines and randomized clinical trials favor the multivessel percutaneous coronary intervention (MV-PCI) strategy undertaken immediately or staged after primary PCI in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease. However, the optimal strategy of MV-PCI remains unknown.
We conducted a search of PUBMED, EMBASE, Web of Science, the Cochrane database (CENTRAL), clinicaltrial.gov, and Google Scholar for studies comparing immediate versus staged MV-PCI in patients with STEMI and multivessel disease. Pooled odds ratios (OR) and 95% confidence intervals (CI) were estimated using random-effects models.
Eighteen (4 randomized clinical trials) studies with 8100 patients fulfilled the inclusion criteria. Relative to staged MV-PCI, immediate MV-PCI was associated with higher short-term (within 30 days) (OR, 3.96; 95% CI, 2.07–7.59; P < 0.0001) and long-term (above 6 months) mortality (OR, 2.12; 95% CI, 1.46–3.07; P < 0.0001), short-term major adverse cardiovascular events (MACE)(OR, 1.99; 95% CI, 1.13–3.50; P = 0.02) and cardiac death (OR, 4.78; 95% CI, 2.17–10.53; P = 0.0001). There was a nonsignificant trend towards higher long-term MACE (OR, 1.23; 95% CI, 0.98–1.54; P = 0.07) and cardiac death (OR, 1.75; 95% CI, 0.93–3.30; P = 0.08) with immediate versus staged MV-PCI. Revascularization, myocardial infarction, and safety endpoints including stroke, major bleeding, and renal failure were similar between immediate versus staged MV-PCI. However, pooled analysis of randomized clinical trials did not show any significant differences in long-term MACE, all-cause mortality, myocardial infarction, and revascularization.
Our meta-analysis suggests that among patients with STEMI and multivessel disease, staged instead of immediate MV-PCI may be the optimal revascularization strategy.
Long-term mortality after ST-elevation myocardial infarction in the reperfusion and modern secondary prevention therapy era according to coronary artery disease extent: The FAST-MI registries
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Historical cohorts have shown extent of coronary artery disease to be a predictor of poorer outcomes in ST-segment elevation myocardial infarction. However, contemporary data in the era of reperfusion and modern secondary prevention therapy are lacking.
To compare 3-year survival in patients with ST-segment elevation myocardial infarction with multivessel disease versus those with single-vessel disease.
Using data from the FAST-MI 2005, 2010 and 2015 registries, three nationwide French surveys, we included all patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention within 24 hours of symptom onset. Baseline characteristics, management and 3-year all-cause mortality were analysed according to coronary status (single-, two- and three-vessel disease).
Among 3907 patients (mean age 62.4 ± 13.7 years; 75.9% male), patients with multivessel disease (two- or three-vessel disease) accounted for 47.9%; overall, they were older, with higher cardiovascular risk profiles. In a multivariable adjusted Cox proportional hazard regression model, only patients with three-vessel disease had a higher rate of mortality at 3 years compared with those with single-vessel disease (hazard ratio 1.52, 95% confidence interval 1.68–2.26; P < 0.001). Finally, patients with multivessel disease with complete myocardial revascularization before discharge had a similar prognosis to patients with single-vessel disease (hazard ratio 1.17, 95% confidence interval 0.84–1.64; P = 0.35).
Multivessel disease still represents an important proportion of patients with ST-segment elevation myocardial infarction. Although three-vessel disease is associated with higher 3-year mortality, patients with multivessel disease and complete myocardial revascularization in the contemporary era have a 3-year risk of death similar to that in patients with single-vessel disease.
Plusieurs cohortes historiques ont montré que l’étendu de la maladie coronaire était un facteur prédictif péjoratif du devenir des patients avec infarctus du myocarde avec sus décalage ST (SCA ST + ). Peu de données récentes sont toutefois disponibles avec les traitements de reperfusion et de prévention secondaire actuels.
Évaluer la survie à 3 ans des patients avec un SCA ST+ pluri tronculaire comparé à ceux mono tronculaires.
A partir des registres FAST-MI 2005, 2010 et 2015, 3 enquêtes nationales, nous avons inclus tous les patients avec un SCA ST+ traités par angioplastie primaire dans les 24 heures après l’apparition des symptômes. Les principales caractéristiques, la prise en charge et la survie à 3 ans de ces patients ont été analysées selon le statu coronaire (1, 2 ou 3 vaisseau[x] atteint[s]).
Parmi les 3907 patients inclus (âge moyen 62,4 ± 13,7 ans ; 75,9 % d’homme), les patients pluri tronculaires représentaient 47,9 %. Globalement, ils étaient plus âgés avec un profil de risque plus sévère. En analyse multi variée, seuls les patients tri tronculaires avaient un sur risque de mortalité à 3 ans par rapport aux patients mono tronculaires (HR 1,52, IC95 % 1,68–2,26 ; p < 0,001). Les patients pluri tronculaires revascularisés complètement (avant la sortie) avaient un pronostic similaire à ceux mono tronculaires (HR 1,17, IC95 % 0,84–1,64 ; p = 0,35).
Les patients pluri-tronculaires représentent encore une proportion importante des SCA ST+. Si l’atteinte tri-tronculaire reste associée à une surmortalité à 3 ans, les patients pluri-tronculaires complètement revascularisés semblent toutefois avoir un pronostic similaire à ceux mono tronculaires avec les traitements de reperfusion et de prévention secondaire modernes.
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Clinical investigationMultivessel percutaneous coronary intervention in patients with multivessel disease and acute myocardial infarction

Abstract

Background

Methods

Results

Conclusions

Section snippets

Study patients

Results

Discussion

Outcome of urgent percutaneous transluminal coronary angioplasty in acute myocardial infarctioncomparison of single-vessel versus multivessel coronary artery disease

Am Heart J

Results of primary angioplasty for acute myocardial infarction in patients with multivessel coronary artery disease

J Am Coll Cardiol

Results of primary angioplasty in patients with multivessel disease [in Spanish]

Rev Esp Cardiol

In-hospital and one-year outcomes for patients undergoing percutaneous coronary intervention for acute myocardial infarction

Am J Cardiol

Primary coronary angioplasty for acute myocardial infarction (the Primary Angioplasty Registry)

Am J Cardiol

Primary angioplasty or thrombolysis for acute myocardial infarction?

Lancet

A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. The Primary Angioplasty in Myocardial Infarction Study Group

N Engl J Med

Multiple complex coronary plaques in patients with acute myocardial infarction

N Engl J Med

Impaired coronary blood flow in nonculprit arteries in the setting of acute myocardial infarction. The TIMI Study Group. Thrombolysis in myocardial infarction

J Am Coll Cardiol

Prognostic implications and predictors of enhanced regional wall motion of the noninfarct zone after thrombolysis and angioplasty therapy of acute myocardial infarction. The TAMI Study Groups

Circulation

Procedural results and late clinical outcomes following multivessel coronary stenting

J Am Coll Cardiol

Clinical investigation
Multivessel percutaneous coronary intervention in patients with multivessel disease and acute myocardial infarction