Coronary Revascularization Strategy for ST Elevation Myocardial Infarction with Multivessel Disease: Experience and Results at 1-Year Follow-Up

Abstract

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 ≥70% stenosis of ≥2 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 follow-up, 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.

Staged versus One-Time Complete Revascularization with Percutaneous Coronary Intervention in STEMI Patients with Multivessel Disease: A Systematic Review and Meta-Analysis

“…Overall, seven studies reported long-term MACE [10,25,27–30,32,34]. There was a trend toward reduced risk of MACE with S-PCI compared with MV-PCI with no heterogeneity, although the trend did not reach statistical significance (OR 0.83, 95% CI 0.62–1.12, P = 0.22, I 2 = 0%), as shown in Fig 4.…”

“…Six studies reported long-term repeat myocardial infarction (re-MI) after long-term follow-up [10,25,27,29,32,34]. There was no significant difference between S-PCI and MV-PCI.…”

Culprit Vessel Only Versus Multivessel and Staged Percutaneous Coronary Intervention for Multivessel Disease in Patients Presenting With ST-Segment Elevation Myocardial Infarction

“…The staged PCI strategy was defined as PCI confined to culprit vessel lesions only, after which Ն1 lesions in nonculprit vessel were treated during planned secondary procedures. The timing of staged PCI procedures was defined as reported in each study (Table 1) (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22).…”

Risk of no-reflow in culprit lesion versus culprit vessel PCI in acute STEMI

“…In this analysis, staged PCI has also been found to be superior to multivessel PCI during the index event. The studies carried out by Politi et al [10], Corpus et al [7], Hannan et al [4], Varani et al [20] and Mohamad et al [21] were included in this analysis, yielding better results with the staged PCI strategy. Only Varani et al [20] found a statistically significant benefit from the staged PCI strategy; the other authors have found better results with staged PCI than multivessel PCI, but these findings were not statistically significant.…”