Comparison of Different Timing of Multivessel Intervention During Index-Hospitalization for Patients With Acute Myocardial Infarction

Abstract

Background: Many patients presenting with acute myocardial infarction (AMI) were found to have a multivessel disease. Uncertainty still exists in the optimal revascularization strategy in AMI patients. The purpose of this study was to assess the outcome of immediate multivessel revascularization compared with staged multivessel percutaneous coronary intervention (PCI) in patients with AMI.Method: This was a nationwide cohort study of 186,112 patients first diagnosed with AMI, 78,699 of whom received PCI for revascularization. Patients who received repetitive PCI during the index hospitalization were referred to as staged multivessel PCI. Immediate multivessel PCI was defined as patients with two-vessel PCI or three-vessel PCI during the index procedure. Cox proportional hazards regression models were performed to evaluate the different indicators of mortality risks in AMI.Result: Immediate multivessel PCI was associated with a worse long-term outcome than staged multivessel PCI during the index admission (log-rank P < 0.001). There was a higher incidence of stroke in patients with multivessel PCI during hospitalization. In Cox analysis, immediate multivessel PCI was an independent risk factor for mortality compared to those with staged multivessel PCI, regardless of the type of myocardial infarction.Conclusion: This study demonstrated that performing immediate multivessel PCI for AMI may lead to worse long-term survival than staged multivessel PCI. Our findings emphasized the importance of PCI timing for non-infarct-related artery stenosis and provided information to supplement current evidence.

Outcomes of Different Reperfusion Strategies of Multivessel Disease Undergoing Newer-Generation Drug-Eluting Stent Implantation in Patients with Non-ST-Elevation Myocardial Infarction and Chronic Kidney Disease

“…In their study [37], the number of patients who received BMS or plain old balloon angioplasty was approximately 18%. More recently, Liu et al [6] demonstrated that immediate M-PCI was associated with worse long-term outcomes than stage M-PCI during index admission (log-rank p < 0.001). However, their study included about 40% of STEMI patients and the deployed stents were not confined to newer-generation DES.…”

“…As shown in Figure 1, patients with cardiogenic shock were excluded in our study. Patients with NSTEMI and cardiogenic shock have worse clinical outcomes than those with STEMI and cardiogenic shock [41] and PCI of the non-IRA may aggravate hemodynamic instability and jeopardize the viable myocardium in the milieu of AMI [6].…”

“…The incidence of MVD in patients with non-ST-segment elevation myocardial infarction (NSTEMI) is more than 50% [2,3]. Even though percutaneous coronary intervention (PCI) for an infarct-related artery (IRA) is a well-established standard treatment [4,5], the treatment strategies for a non-IRA in the NSTEMI milieu are still debatable [6][7][8][9]. Revascularization of the non-IRA may reduce the incidence of recurrent ischemia, improve left ventricular function, reduce arrhythmias and potentially improve hemodynamics [10].…”

Long‐term outcomes after stent implantation in very small vessel coronary artery disease

“…Obstructive lesions with smaller RVD can still affect the coronary blood flow and myocardial perfusion and result in angina, impaired quality of life, and ventricular arrhythmias 30 . Some studies have also indicated that complete revascularization in patients with CKD may attenuate the risk of sudden death or lethal arrhythmia by increasing the myocyte reserve to handle fluxes in fluid and electrolytes or transient changes in sympathetic tone 31–33 . However, PCI of very small vessels may expose these patients to acute procedural complications, increase their risk of bleeding from dual‐antiplatelet therapy, and subsequent restenosis requiring repeated angioplasty 34–36 .…”

“…30 Some studies have also indicated that complete revascularization in patients with CKD may attenuate the risk of sudden death or lethal arrhythmia by increasing the myocyte reserve to handle fluxes in fluid and electrolytes or transient changes in sympathetic tone. 31 , 32 , 33 However, PCI of very small vessels may expose these patients to acute procedural complications, increase their risk of bleeding from dual‐antiplatelet therapy, and subsequent restenosis requiring repeated angioplasty. 34 , 35 , 36 In general, treatment strategies should be individualized for this high‐risk population of patients with CKD.…”