Complete Revascularisation in ST-elevation MI: Do We Really Buy It? Challenging the Current Approach to Bystander Percutaneous Coronary Intervention

Total revascularization of coronary disease at the time of primary percutaneous coronary intervention.

Contemporary Management of Patients with ST Elevation Myocardial Infarction

Left Anterior Descending Nonculprit Lesions and Clinical Outcomes in PatientsWith ST-Segment Elevation Myocardial Infarction.

The recent randomized trials demonstrated that culprit-only percutaneous coronary intervention (CO-PCI) was superior to multivessel PCI (MV-PCI) among ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease (MVD) complicated by cardiogenic shock, yet the real-world scenario remains to be determined. Studies that compared CO-PCI versus MV-PCI in STEMI patients with MVD complicated by cardiogenic shock were identified by a systematic search of published articles. Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated by using random-effects models. Eventually, 18 observational studies involving 73,528 patients were included. The results showed that CO-PCI was associated with lower risks of short-term renal failure (OR: 0.75; 95% CI: 0.64 to 0.88; I2=14.7%) and short-term stroke (OR: 0.86; 95% CI: 0.77 to 0.96; I2=0.0%) compared with immediate MV-PCI. But the risk of short-term myocardial infarction (OR: 1.12; 95% CI: 1.03 to 1.22; I2=0.0%) was increased. There was no significant difference during long-term follow-up. The results remained consistent after adding the only randomized trial. Based on real-world analyses, our meta-analysis suggested that CO-PCI decreased the risks of renal failure and stroke but increased the risk of myocardial infarction relative to immediate MV-PCI during short-term follow-up in STEMI patients with MVD complicated by cardiogenic shock. If possible in clinical practice, staged MV-PCI can be given a try to decrease the risks of renal failure and stroke associated with immediate MV-PCI and myocardial infarction associated with CO-PCI. However, the conclusions need to be confirmed by further large-scale studies.

Current guidelines recommend that percutaneous coronary intervention (PCI) should be restricted to the culprit vessel in ST elevation myocardial infarction (STEMI) patients with multi-vessel disease (MVD) and without cardiogenic shock. However, newer data suggests that performing complete revascularization (CR) in MVD patients may lead to better outcomes compared to intervention in the culprit vessel only. The aim of this meta-analysis is to examine the available data to determine if CR (using either angio- or fractional flow reserve guidance-FFR) following primary PCI in STEMI patients without cardiogenic shock impacts clinical outcomes. Meta-analysis was performed by conducting a literature search of PubMed from January 2004 to July 2017. Pooled estimates of outcomes, presented as odds ratios (OR) [95% confidence intervals], were generated using random-effect models. A total of 9 studies (3317 patients) were included. CR showed a significant MACE reduction (OR 0.49, 95% CI 0.36-0.66, p < 0.001); All-cause mortality (OR 0.69, 95% CI 0.48-0.98, p = 0.04) and repeat revascularization (OR 0.38, 95% CI 0.28-0.51, p < 0.001) at ≥ 12months follow-up. The FFR-guiding CR group presented a MACE reduction (odds ratio 0.52, 95% CI 0.30-0.90, p = 0.02) due to a decrease of repeat revascularization (OR 0.41, 95% CI 0.21-0.80, p = 0.009). Overall, performing complete revascularization in STEMI patients showed a MACE reduction, all-cause death and repeat revascularization. Compared to culprit-only revascularization, treating multi-vessel disease in STEMI patients using FFR guidance is associated with decreased incidence of MACE, due to a decreased rate of revascularization.

P5476Usefulness of haemoglobin level combined with CAMI-STEMI score for predicting MACCE in patients with acute ST-elevation myocardial infarction after PCI

Complete Revascularization Versus Culprit Lesion Only in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Disease: A DANAMI-3–PRIMULTI Cardiac Magnetic Resonance Substudy

Background: The optimal therapeutic strategy for ST-segment elevation myocardial infarction (STEMI) patients found to have multi-vessel disease (MVD) is controversial but recent data support complete revascularisation (CR). Whether CR should be completed during the index admission or during a second staged admission remains unclear. Our main objective was to measure rates of major adverse cardiovascular events (MACEs) during the waiting period in STEMI patients selected for staged revascularisation (SR), in order to determine the safety of delaying CR. For completeness, we also describe 30-day and long-term outcomes in STEMI patients with MVD who underwent in-hospital CR.Methods: A single-centre retrospective analysis of 931 STEMI patients treated by primary percutaneous coronary intervention (PCI) identified 397 patients with MVD who were haemodynamically stable and presented within 12 hours of chest pain onset. Of these, 191 underwent multi-vessel PCI: 49 during the index admission and 142 patients undergoing a strategy of SR.Results: Our main finding was that waiting period MACE were 2% (three of 142) in patients allocated to SR (at a median of 31 days). In patients allocated to in-hospital CR, 30-day MACE rates were 10% (five of 49). During a median follow up of 39 months, all-cause mortality was 7.0% vs. 28.6%, and cardiac mortality was 2% vs. 8%, in patients allocated to SR or CR, respectively.Conclusions: Patients with STEMI and MVD who, based on clinical judgement, were allocated to a second admission SR strategy had very few adverse events during the waiting period and excellent long-term outcomes.

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The optimum timing of revascularization strategy for stenoses in nonculprit vessels in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) remains unclear. At present, there is no evidence investigating the outcome of staged percutaneous coronary intervention (PCI) within two weeks from admission among STEMI patients with MVD. A total of 210 STEMI patients with MVD who underwent primary PCI were analyzed. We compared the all-cause mortality and major adverse cardiovascular events (MACE) (cardiovascular death, myocardial infarction, heart failure, unstable angina, and stroke) with median follow-up of 1200 days among the patients who underwent staged PCI within two weeks from admission (staged PCI ≤2 W) (n = 75), staged PCI after two weeks from admission (staged PCI >2 W) (n = 37) and culprit-only PCI (n = 98) in patients with STEMI and MVD. The staged PCI ≤2 W showed lower all-cause mortality than culprit-only PCI (4.0 vs 29.6%, log-rank P = 0.001), and lower incidence of MACE than the staged PCI >2 W group (1.3 vs 18.9%, log-rank P = 0.001) and culprit-only PCI group (1.3 vs 22.5%, log-rank P = 0.001). In the multivariable Cox regression analysis, the staged PCI ≤2 W was a predictor of lower all-cause mortality (hazard ratio [HR], 0.176; 95% confidence interval [CI], 0.049-0.630; P = 0.008) and lower incidence of MACE (HR, 0.068; 95% CI, 0.009-0.533; P = 0.011), but staged PCI >2 W was not. In conclusion, staged PCI within two weeks after admission showed more favorable outcomes compared with staged PCI after two weeks from admission or culprit-only PCI in STEMI patients with MVD.

A Multidisciplinary Approach to Reducing Door-to-Balloon Time in a Community Hospital

Background: Morphine is commonly used for analgesia in the setting of chest discomfort associated with acute coronary syndromes (ACS). However, a retrospective analysis in non-ST elevation acute coronary syndrome (NSTE-ACS) patients suggesting increased mortality with morphine administration and further studies suggesting morphine may delay and inhibit the absorption of the oral anti-platelet agents has placed its utility in ACS under closer scrutiny. In a large single center retrospective study, we analyzed the association between morphine and in-hospital outcomes in ST elevation myocardial infarction (STEMI) and NST-ACS patients undergoing coronary angiogram +/- percutaneous coronary intervention (PCI). Methods: All STEMI and NSTE-ACS patients undergoing PCI between January 2009 and July 2016 in Massachusetts General Hospital were included in our study. Following institutional board review approval, baseline patient characteristics (demographics, risk factors and medical history) was obtained. In-hospital outcomes included mortality, post-procedure cardiogenic shock, length of hospital stay and infarct size as measured by troponin level. Results: Overall, 3027 patients were examined. Of those, 1287/3027 (42.52%) had STEMI, of which 359/1287 patients received morphine (27.89%). STEMI patients who received morphine were younger, had a higher prevalence of prior MI, PCI, and angina, were more likely to be on oxygen therapy, and had a longer time to PCI. 1740/3027 (57.48%) of study patients had NST-ACS, of which 424 (24.37%) received morphine. NSTE-ACS patients who received morphine were younger, had a higher prevalence of cerebrovascular disease, peripheral vascular disease, prior PCI, MI, congestive heart failure and valvular surgery. In unadjusted outcomes, STEMI patients who received morphine had a lower in-hospital mortality [4.18% versus 7.54%, odds ratio (OR): 0.53, p=0.03] and smaller infarct size (mean troponin level 0.75 ng/ml versus 1.29 ng/ml, p=0.02). There was no significant difference in post procedure cardiogenic shock or length of hospital stay (p= 0.26 and p=0.29 respectively). After adjusting for basic characteristics no outcomes remained significant in the STEMI cohort. In the NST-ACS cohort, patients who received morphine had a longer hospital stay (mean 6.58 days versus 4.78 days, p&lt;0.0001) and larger infarct size (mean troponin 1.16 ng/ml versus 0.90 ng/ml, p= 0.05). There was no statistical difference in in-hospital mortality or cardiogenic shock (p=0.17 and p=0.80 respectively). After adjusting for basic characteristics, length of hospital stay (p &lt;0.0001) and infarct size (p=0.02) remained significant. Conclusion: In a large retrospective study, morphine was associated with larger infarct size and a longer hospital admission in NSTE-ACS patients but had no effect on outcomes in STEMI patients.

Completeness of revascularization in relation to major cardiovascular events in patients with ST-elevation myocardial infarction and multivessel disease: results from the COMPLETE trial

Complete versus culprit-only revascularization during primary percutaneous coronary intervention in ST-elevation myocardial infarction patients with multivessel disease: A meta-analysis

Multi-vessel coronary disease in people with ST elevation myocardial infarction (STEMI) is common and is associated with worse prognosis after STEMI. Based on limited evidence, international guidelines recommend intervention on only the culprit vessel during STEMI. This, in turn, leaves other significantly stenosed coronary arteries for medical therapy or revascularisation based on inducible ischaemia on provocative testing. Newer data suggest that intervention on both the culprit and non-culprit stenotic coronary arteries (complete intervention) may yield better results compared with culprit-only intervention. To assess the effects of early complete revascularisation compared with culprit vessel only intervention strategy in people with STEMI and multi-vessel coronary disease. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, World Health Organization International Clinical Trials Registry Platform Search Portal, and ClinicalTrials.gov. The date of the last search was 4 January 2017. We applied no language restrictions. We handsearched conference proceedings to December 2016, and contacted authors and companies related to the field. We included only randomised controlled trials (RCTs), wherein complete revascularisation strategy was compared with a culprit-only percutaneous coronary intervention (PCI) for the treatment of people with STEMI and multi-vessel coronary disease. We assessed the methodological quality of each trial using the Cochrane 'Risk of bias' tool. We resolved the disagreements by discussion among review authors. We followed standard methodological approaches recommended by Cochrane. The primary outcomes were long-term (one year or greater after the index intervention) all-cause mortality, long-term cardiovascular mortality, long-term non-fatal myocardial infarction, and adverse events. The secondary outcomes were short-term (within the first 30 days after the index intervention) all-cause mortality, short-term cardiovascular mortality, short-term non-fatal myocardial infarction, revascularisation, health-related quality of life, and cost. We analysed data using fixed-effect models, and expressed results as risk ratios (RR) with 95% confidence intervals (CI). We used GRADE criteria to assess the quality of evidence and we conducted Trial Sequential Analysis (TSA) to control risks of random errors. We included nine RCTs, that involved 2633 people with STEMI and multi-vessel coronary disease randomly assigned to either a complete (n = 1381) versus culprit-only (n = 1252) revascularisation strategy. The complete and the culprit-only revascularisation strategies did not differ for long-term all-cause mortality (65/1274 (5.1%) in complete group versus 72/1143 (6.3%) in culprit-only group; RR 0.80, 95% CI 0.58 to 1.11; participants = 2417; studies = 8; I2 = 0%; very low quality evidence). Compared with culprit-only intervention, the complete revascularisation strategy was associated with a lower proportion of long-term cardiovascular mortality (28/1143 (2.4%) in complete group versus 51/1086 (4.7%) in culprit-only group; RR 0.50, 95% CI 0.32 to 0.79; participants = 2229; studies = 6; I2 = 0%; very low quality evidence) and long-term non-fatal myocardial infarction (47/1095 (4.3%) in complete group versus 70/1004 (7.0%) in culprit-only group; RR 0.62, 95% CI 0.44 to 0.89; participants = 2099; studies = 6; I2 = 0%; very low quality evidence). The complete and the culprit-only revascularisation strategies did not differ in combined adverse events (51/2096 (2.4%) in complete group versus 57/1990 (2.9%) in culprit-only group; RR 0.84, 95% CI 0.58 to 1.21; participants = 4086; I2 = 0%; very low quality evidence). Complete revascularisation was associated with lower proportion of long-term revascularisation (145/1374 (10.6%) in complete group versus 258/1242 (20.8%) in culprit-only group; RR 0.47, 95% CI 0.39 to 0.57; participants = 2616; studies = 9; I2 = 31%; very low quality evidence). TSA of long-term all-cause mortality, long-term cardiovascular mortality, and long-term non-fatal myocardial infarction showed that more RCTs are needed to reach more conclusive results on these outcomes. Regarding long-term repeat revascularisation more RCTs may not change our present result. The quality of the evidence was judged to be very low for all primary and the majority of the secondary outcomes mainly due to risk of bias, imprecision, and indirectness. Compared with culprit-only intervention, the complete revascularisation strategy may be superior due to lower proportions of long-term cardiovascular mortality, long-term revascularisation, and long-term non-fatal myocardial infarction, but these findings are based on evidence of very low quality. TSA also supports the need for more RCTs in order to draw stronger conclusions regarding the effects of complete revascularisation on long-term all-cause mortality, long-term cardiovascular mortality, and long-term non-fatal myocardial infarction.