Ischemia-guided vs routine non-culprit vessel angioplasty for patients with ST segment elevation myocardial infarction and multi-vessel disease: the IAEA SPECT STEMI trial

Abstract

Background In patients with multi-vessel disease presenting with ST elevation myocardial infarction (STEMI), the efficacy and safety of ischemia-guided, vs routine non-culprit vessel angioplasty has not been adequately studied. Methods We conducted an international, randomized, non-inferiority trial comparing ischemia-guided non-culprit vessel angioplasty to routine non-culprit vessel angioplasty, following primary PCI for STEMI. The primary outcome was the between-group difference in percent ischemic myocardium at follow-up stress MPI. All MPI images were processed and analyzed at a central core lab, blinded to treatment allocation. Results In all, 109 patients were enrolled from nine countries. In the ischemia-guided arm, 25/48 (47%) patients underwent non-culprit vessel PCI following stress MPI. In the routine non-culprit PCI arm, 43/56 (77%) patients underwent angioplasty (86% within 6 weeks of randomization). The median percentage of ischemic myocardium on follow-up imaging (mean 16.5 months) was low, and identical (2.9%) in both arms (difference 0.13%, 95%CI − 1.3%–1.6%, P < .0001; non-inferiority margin 5%). Conclusion A strategy of ischemia-guided non-culprit PCI resulted in low ischemia burden, and was non-inferior to a strategy of routine non-culprit vessel PCI in reducing ischemia burden. Selective non-culprit PCI following STEMI offers the potential for cost-savings, and may be particularly relevant to low-resource settings. (CTRI/2018/08/015384).

Revascularization of non-culprit lesions: A common dilemma

“…Moreover, previous studies demonstrated that the changes in perfusion parameters, obtained early and 6 months after acute myocardial infarction, have a great prognostic impact in predicting long-term outcome. 29 In Karthikeyan et al 28 investigation, including a mean time between the two imaging studies of 16.5 months, no data on subsequent follow-up are reported. Moreover, despite the amount of ischemia at imaging after revascularization was comparable between routine non-culprit PCI vs. image guided PCI, the authors suggest that selective non-culprit PCI following STEMI offers the potential for cost-savings and may be particularly relevant to low-resource settings.…”

“…In the current issue of the Journal, Karthikeyan et al 28 conducted an international, randomized, non-inferiority trial comparing ischemia-guided non-culprit vessel angioplasty to routine non-culprit vessel angioplasty, following primary PCI for STEMI (IAEA SPECT STEMI trial). They hypothesized that a strategy of systematic noninvasive assessment of inducible ischemia to guide decisions regarding non-culprit PCI, will be noninferior to routine non-culprit PCI, in reducing ischemia burden.…”

“…Therefore, they concluded that a strategy of ischemia-guided non-culprit PCI resulted in low ischemia burden and was non-inferior to a strategy of routine non-culprit vessel PCI in reducing ischemia burden. Karthikeyan et al 28 aimed to clarify the best strategy in patients with evidence of additional non-culprit lesions after STEMI; however, the topic is complex, and some points should be highlighted and discussed. First, Karthikeyan et al 28 proposed a prospective trial on a limited number of patients, in which the occurrence of COVID-19 pandemic status strongly affected the access to nuclear medicine facilities.…”

“…Karthikeyan et al 28 aimed to clarify the best strategy in patients with evidence of additional non-culprit lesions after STEMI; however, the topic is complex, and some points should be highlighted and discussed. First, Karthikeyan et al 28 proposed a prospective trial on a limited number of patients, in which the occurrence of COVID-19 pandemic status strongly affected the access to nuclear medicine facilities. This limitation may have affected the results and the lack of differences between non-culprit PCI vs. image guided PCI may be partially related to these factors.…”

“…Therefore, despite the results from the IAEA SPECT STEMI trial 28 provide encouraging preliminary data in this setting of a selective approach, the benefits of routine revascularization of non-culprit obstructive CAD in STEMI patients remain to be fully addressed. In order to identify the optimal patient centric approach to this dilemma further data are needed.…”