Complete Revascularization of Multivessel Coronary Artery Disease Does Not Improve Clinical Outcome in ST-Segment Elevation Myocardial Infarction Patients with Reduced Left Ventricular Ejection Fraction

Jeehoon Kang,Jung-Kyu Han,Hyun-Jae Kang,Kyung Woo Park,Han-Mo Yang,Hyo-Soo Kim,Bon-Kwon Koo,Hak Seung Lee,Jiesuck Park,Chengbin Zheng,Taemin Rhee

doi:10.3390/jcm9010232

Abstract

The benefit of complete revascularization (CR) in ST-segment elevation myocardial infarction (STEMI) patients with left ventricular (LV) dysfunction is uncertain. A total of 1314 STEMI patients with multivessel coronary artery disease were analyzed. CR was defined angiographically and by a residual Synergy between PCI with Taxus and Cardiac Surgery trial (SYNTAX) score (SS) <8. Patients with a left ventricular ejection fraction (LVEF) <40% were classified as the reduced LVEF group. The major study endpoints were patient-oriented composite outcome (POCO) and cardiac death during three-year follow-up. Overall, patients that received angiographic CR (579 patients, 44.1%) had significantly lower three-year clinical events compared with incomplete revascularization (iCR). CR reduced three-year POCO and cardiac death rates in the preserved LVEF group (POCO: 13.2% vs. 21.9%, p < 0.001, cardiac death: 1.8% vs. 6.5%, p < 0.001, respectively) but not in the reduced LVEF group (POCO: 26.0% vs. 33.1%, p = 0.275, cardiac death: 15.1% vs. 19.0%, p = 0.498, respectively). Multivariate analysis showed that CR significantly reduced three-year POCO (hazard ration (HR) 0.59, 95% confidence interval (CI) 0.43–0.82) and cardiac death (HR 0.34, 95% CI 0.14–0.80), only in the preserved LVEF group. Additionally, the results were corroborated using the SS-based CR definition. In STEMI patients with multivessel disease, CR did not improve clinical outcomes in those with reduced LVEF.

Highlights

Current guidelines advocate percutaneous coronary intervention (PCI) for non-culprit arteries in ST-segment elevation myocardial infarction (STEMI) patients who are hemodynamically stable [1,2,3]
The recommendation is supported by four recent randomized clinical trials (RCT) that confirmed the beneficial effect of complete revascularization (CR) in multivessel STEMI patients [4,5,6,7]
The Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) trial showed that CR could not reduce mortality in STEMI patients with cardiogenic shock [8], stressing that additional evidence is needed for CR in high-risk STEMI patients

Summary

Introduction

Current guidelines advocate percutaneous coronary intervention (PCI) for non-culprit arteries in ST-segment elevation myocardial infarction (STEMI) patients who are hemodynamically stable [1,2,3]. The recommendation is supported by four recent randomized clinical trials (RCT) that confirmed the beneficial effect of complete revascularization (CR) in multivessel STEMI patients [4,5,6,7]. In these studies, CR which was achieved through either a one-step or staged procedure, improved clinical outcomes compared with incomplete revascularization (iCR) by 45–65% at follow-up ranging from one to three years, the primary endpoints were slightly different according to each study. Previous RCTs had strict inclusion criteria, only including patients who were hemodynamically stable, and patients with few clinical risk factors. The Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) trial showed that CR could not reduce mortality in STEMI patients with cardiogenic shock [8], stressing that additional evidence is needed for CR in high-risk STEMI patients

Methods

Results

Conclusion