Complete Revascularization Research Articles

Impact of complete revascularization on long-term clinical outcomes in patients with multi-vessel disease, including chronic total occlusion.

To compare the long-term prognostic effect of complete percutaneous coronary intervention (PCI) on cardiovascular events in chronic total occlusion (CTO) patients with the multi-vessel disease (MVD) compared with medical therapy (MT). We enrolled 441 patients with CTO and MVD who underwent PCI. The study population was divided into the CTO-PCI (n = 231) and the CTO-MT (n = 210) groups. Active PCI for non-CTO lesions was permitted in both groups. The primary endpoint was defined as the composite of all-cause death or myocardial infarction (MI). The primary endpoint occurred more frequently in the CTO-MT group (13.5%) than in the CTO-PCI group (4.7%; P = 0.002). However, the target vessel revascularization (TVR), as a secondary endpoint, occurred more in the CTO-PCI group (16.3% vs. 5.5%, P = 0.001). After propensity score matching (PSM) analysis, the primary endpoint was higher in the CTO-MT group (12.6%) than in the PCI group (2.3%): all-cause death (8.4% vs. 2.3%, P = 0.042) and MI (4.3% vs. 0.0%, P = 0.023). Moreover, TVR of the CTO lesions occurred more frequently in the CTO-PCI group (18.1% vs. 6.8%, P = 0.009). Significant improvement in the left ventricular ejection fraction (LVEF) was observed in both groups. According to the results of the subgroup analysis, CTO-PCI may be more effective in patients with diabetes, preserved LVEF (> 50%), and well-developed collateral vessels (> grade II). In this study, complete revascularization in CTO with MVD reduced the incidence of all-cause death, MI, and a composite of both over a 5year follow-up compared to medical treatment for CTO lesions.

A Meta-Analysis of Timing of Complete Revascularization in Patients with ST-Elevation Myocardial Infarction

Background: Recent randomized clinical trials (RCTs) of STEMI patients with multi-vessel disease (MVD) reported potential superiority of immediate (ICR) vs. staged complete revascularization (SCR). Inherently, the risk of procedural MI is less likely to be detected in ICR patients, and this may have influenced the results. Recently published meta-analyses encompassed observational studies without including STEMI data from the BioVasc trial. The aim of this meta-analysis was to perform an updated comparison of the two strategies in STEMI patients with MVD. Methods: Electronic databases were searched from their inception till August 2024 to identify RCTs assessing CR timing in STEMI patients with MVD. Only studies with an endpoint involving major adverse cardiovascular events (MACE) were included. Results: Six RCTs totaling 2023 patients were included in the analysis. The median time to staged PCI was 19 days. The incidence of MACE (as defined by each study’s protocol) was comparable between the two strategies [RR 0.86, 95% CI (0.58 to 1.27)]. There was also no difference in the risk of non-procedural MI [RR 0.91, 95% CI (0.49–1.67)], death [RR 1.47, 95% CI (0.89–2.44)] and cardiovascular death [RR 1.53, 95% CI (0.79–2.98)]. There was a significant 40% reduction in unplanned revascularization in patients undergoing ICR versus SCR [RR 0.60 (0.40 to 0.89), p = 0.01]. Conclusions: ICR reduced the risk of unplanned revascularization compared to SCR but had a comparable effect on MACE, death, cardiovascular death and non-procedural MI. Both strategies are safe in managing patients with acute MI and MVD.

Abstract 4135984: Comparison of Immediate and Staged Complete Revascularization in STEMI Patients with Multivessel Disease: Meta-Analysis of Randomized Controlled Trial

Background: Patients diagnosed with ST-segment elevation myocardial infarction (STEMI) frequently present with multivessel coronary artery disease (CAD) at the time of primary percutaneous coronary intervention (PCI). The optimal timing of complete revascularization (CR) in these cases remains a subject of ongoing debate. Objective: To assess major cardiovascular outcomes and procedural complications in STEMI patients with multivessel CAD undergoing immediate versus staged CR post index procedure. Methods: We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing immediate to staged CR in STEMI and multivessel CAD. Trials were identified via a systematic search of MEDLINE, Embase, and Cochrane Libraries from database inception to March 6, 2024. The data were analyzed using RevMan software. Results: Among five RCTs (n=1,415) the majority of participants were male, the weighted mean follow-up duration across studies was 15.6 months. Immediate versus staged CR showed no significant differences in MACE (13.3% vs 9.8%; RR: 1.07, 95% CI [0.62, 1.83]), all-cause mortality (3% vs 4.55%; RR: 0.70, 95% CI [0.41, 1.21]), or MI (4.5% vs 2.6%; RR: 1.43, 95% CI [0.58, 3.55]). However, the staged group had higher unplanned revascularization incidence (8.6% vs 4.4%; RR: 1.92, 95% CI [1.21, 3.04]). Conclusion: Staged revascularization in STEMI patients with multivessel CAD demonstrates comparable effectiveness to immediate revascularization but leads to a greater number of unplanned revascularization procedures, likely due to delayed intervention. The early implementation of staged PCI during the initial hospitalization phase may provide equivalent efficacy to immediate complete revascularization. Nonetheless, further research is necessary to corroborate these findings.

Abstract 4143258: Sex Differences in Health Status Outcomes: Analysis of the ISCHEMIA Randomized Clinical Trial

Background: Despite a lesser extent and severity of coronary artery disease (CAD), women had a higher burden of angina than men in the ISCHEMIA trial, suggesting that other factors may explain symptom severity in women. We aim to describe demographic and clinical characteristics, as well as differences in care patterns, associated with health status differences in women, as compared with men, in the conservative and invasive treatment groups of the ISCHEMIA trial. Methods: The ISCHEMIA trial randomized participants with moderate or severe ischemia to a routine invasive strategy of cardiac catheterization with complete revascularization plus guideline-directed medical therapy (GDMT), or an initial conservative strategy of GDMT alone with catheterization reserved for GDMT failure. Health status was a key secondary outcome. Using linear regression models we compared raw and adjusted Seattle Angina Questionnaire (SAQ) scores in women and men at baseline and at 1 year, stratified by randomized treatment strategy. Within the invasive strategy, sex differences were adjusted for completeness of revascularization among those with ≥1 coronary stenosis ≥70%. Results: Of 4,617 ISCHEMIA participants with valid SAQ data, women had lower (worse) baseline SAQ summary scores (SS) throughout follow up (Figure) after adjustment for demographics and clinical characteristics, including severity of CAD (difference 5.4 points, 95% CI 4.0-6.7). Women had lower SAQ SS after adjustment for post-randomization treatment (i.e., medical therapy, achievement of risk factor goals and, in the invasive strategy, complete revascularization), 2.4 points lower (95% CI 0.7-4.1) in the conservative group (Figure), and 1.9 points lower than in men (95% CI 0.1-3.7) in the invasive group. Findings were similar for all SAQ subscales. Conclusions: Women with chronic coronary disease in ISCHEMIA had worse health status than men at baseline and 1 year later, which was not explained by demographic or clinical characteristics, intensity of medical therapy, or completeness of revascularization.

Abstract 4123864: Fractional flow reserve-guided complete revascularization versus culprit-only revascularization in patients with myocardial infarction and multivessel disease: A GRADE assessed meta-analysis of randomized controlled trials

Background: Fractional flow reserve (FFR) guided complete revascularization (CR) is an approach that can be used to improve clinical outcomes in patients with acute myocardial infarction (MI) and multivessel disease (MVD). The objective of the present meta-analysis was to investigate whether FFR-guided CR leads to better cardiovascular outcomes as compared to culprit-only revascularization (COR) in acute MI and MVD by pooling recently published data. Methods: A comprehensive literature search was conducted using PubMed/MEDLINE, Embase, and the Cochrane Library from inception until April 2024 to retrieve eligible randomized controlled trials (RCTs). Clinical outcomes were assessed using the random-effects model by pooling risk ratios (RRs) along with 95% confidence intervals (CIs). We assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Results: Four RCTs were pooled with 3,175 patients. FFR-guided CR significantly reduced the risk of repeat revascularization as compared to COR (RR = 0.52; 95% CI: 0.33-0.81, p = 0.004) [absolute risk difference 83 fewer per 1,000 patients (95% confidence interval: 116 to 33 fewer) moderate certainty]. Though there was a reduction in the risk of MACE with FFR-guided CR (RR = 0.68, 95% CI: 0.44-1.04, p = 0.08; moderate certainty), it didn't attain statistical significance. Clinical outcomes such as all-cause death (RR = 1.10, 95% CI: 0.84-1.45, p = 0.48; moderate certainty), cardiac death (RR = 0.79, 95% CI: 0.53-1.17, p = 0.24; high certainty), risk of MI (RR = 0.94, 95% CI: 0.54-1.66, p = 0.84; moderate certainty) and major bleeding (RR = 0.95, 95% CI: 0.54-1.67, p = 0.87; moderate certainty) were comparable between the two groups. Conclusion: FFR-guided CR in patients with MI and MVD can lead to a decreased risk of repeat revascularizations while not affecting all-cause and cardiac deaths.

Abstract 4132742: Fractional flow reserve guided complete revascularization versus Culprit-only percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease. A meta-analysis of randomized controlled trials

Background: Data comparing the efficacy and safety of fractional flow reserve (FFR)-guided complete revascularization (CR) to culprit-only percutaneous coronary artery intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease are limited. Method: Pubmed, Embase and Cochrane were searched for randomized controlled trails (RCTs) comparing FFR-guided CR to Culprit-only PCI in patients with STEMI and multivessel CAD. A meta-analysis was performed on primary outcomes of major adverse cardiac events (MACE) and all-cause mortality. Heterogeneity was examined with I 2 statistics. A random-effects model was used for outcomes with high heterogeneity. Results: We included 4 RCTs with 3173 patients comparing FFR-guided CR with culprit-only PCI in patients with STEMI and multivessel coronary artery diseases. The pooled results of the 4 RCTs showed that MACE (RR=0.66; 95% CI [0.45, 0.99]; p=0.01; 16.8% vs 24.1%), PCI revascularization (RR=0.50; 95% CI [0.37, 0.67]; p<0.00001; 13.1% vs 24.9%) and unplanned revascularization (RR=0.66; 95% CI [0.44, 0.99]; p=0.04; 8.7% vs 12.9%) were significantly reduced in the FFR-guided complete revascularization group compared to culprit-only PCI group. However, all-cause mortality (RR=1.09; 95% CI [0.84, 1.42]; p=0.53; 7.2% vs 6.0%), stroke (RR=1.02; 95% CI [0.38, 2.75]; p =0.97; 2.0% vs 1.8%), major bleeding (RR=0.95; 95% CI [0.54, 1.67]; p=0.87; 1.7% vs 1.7%), death from cardiovascular causes (RR=0.82; 95% CI [0.55, 1.21]; p=0.31; 3.1% vs 3.4%), MI (RR=1.09; 95% CI [0.60, 1.95]; p=0.78; 6.7% vs 6.4%), rehospitalization for HF (RR=0.72; 95% CI [0.44, 1.15]; p=0.17; 3.4% vs 5.3%), death from any cause or MI (RR=1.02; 95% CI [0.61, 1.71]; p=0.95; 14.9% vs 13.6%), any stent thrombosis (RR=1.42; 95% CI [0.35, 5.72]; p=0.62; 2.2% vs 1.4%), contrast induced nephropathy (RR=0.25; 95% CI [0.02, 2.79]; p=0.26), and CABG revascularization (RR=1.25; 95% CI [0.30, 5.15]; p=0.76) were not statistically different between groups. Conclusion: Our meta-analysis suggests that FFR-guided CR is safe and has superior efficacy to Culprit-only PCI in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease with significantly lowered incidence of MACE, PCI revascularization as well as unplanned or urgent revascularization. However, FFR-guided CR showed no beneficial effect on all-cause mortality, stroke, major bleeding and myocardial infarction.

High-risk features in non-culprit lesions and clinical outcome after NSTEMI versus STEMI.

Complete non-culprit (NC) revascularization may help reduce recurrent events after NSTEMI, especially if NC lesions would harbor high-risk plaque features similar to STEMI. The study aimed to assess differences in fractional flow reserve (FFR)-negative NC plaque morphology in patients presenting with NSTEMI versus STEMI and assess the association of high-risk plaque morphology and clinical outcome. In the prospective PECTUS-obs study, 438 patients presenting with myocardial infarction (MI) underwent optical coherence tomography (OCT) of all FFR-negative intermediate NC lesions. The primary endpoint was the occurrence of major adverse cardiovascular events (MACE, all-cause mortality, non-fatal MI or unplanned revascularization) at two-year follow-up. Four hundred and twenty patients had at least one analyzable OCT, including 203 (48.3%) with NSTEMI and 217 (51.7%) with STEMI. The prevalence of high-risk plaques (HRP), including thin-cap fibroatheromas (TCFA), plaque rupture and thrombus, was comparable between groups. MACE occurred in 29 (14.3%) NSTEMI patients and 16 (7.4%) STEMI patients (Punivariable=0.025 and Pmultivariable=0.270). Incidence of MACE was numerically higher among patients with HRP, irrespective of the clinical presentation at index (Pinteraction=0.684). Among high-risk plaque criteria, plaque rupture was associated with MACE in both NSTEMI (p<0.001) and STEMI (p=0.020). Presence of NC HRP is comparable between NSTEMI and STEMI and leads to numerically higher event rates in both. These results call for additional research on complete revascularization in NSTEMI and treatment of HRP.

Complete versus culprit-only coronary revascularization in patients with myocardial infarction and multivessel disease undergoing percutaneous coronary intervention: an updated meta-analysis.

Recently, the FFR-Guidance for Complete Nonculprit Revascularization (FULL REVASC) trial in ST elevation myocardial infarction (STEMI) patients with multiple vessel disease (MVD) did not show differences in the composite endpoint of death from any cause, myocardial infarction, or unplanned revascularization than culprit-lesion-only percutaneous coronary intervention (PCI) at 4.8 years, although complete revascularization is a recommendation IA in current guidelines. We want to determine through an updated meta-analysis whether complete revascularization is associated with decreased mortality and hard clinical endpoints compared to culprit lesion only PCI. We searched MEDLINE, Embase, ISI Web of Science, and Cochrane Central Register of Controlled Trials) from January 1990 to April 2024 using the terms "percutaneous coronary intervention" combined with "non culprit lesions" or "culprit lesion" or "complete revascularization" or "incomplete revascularization." Additionally, a "snowball search" was conducted. Only randomized clinical trials (RCT) reporting mortality, re-infarction or new revascularization after at least 12 months and using predominantly drug eluting stents were included. The summary effect of different revascularization strategies on cardiovascular endpoints was estimated and measures of effect size were expressed as odds ratios (ORs). Eight RCT involving 9515 patients were included, with a follow-up range between 12 months and 4.8 years. Main findings show that culprit lesion revascularization was associated with an increased risk of MI (OR: 1.38; 95% CI: 1.05 to 1.81, I2 42%) and ischemia-guided revascularization (OR: 2.81; 95% CI: 1.86 to 4.26, I2 80%) compared to complete revascularization, without differences in overall mortality (OR: 1.15; 95% CI: 0.98 to 1.36, I2 2%). In patients with STEMI and MVD without cardiogenic shock, our metanalysis showed that complete revascularization with PCI significantly reduced the risk of non-fatal myocardial reinfarction and ischemic-driven revascularization compared to culprit vessel-only revascularization, without differences in overall mortality.

Outcomes after percutaneous coronary intervention or bypass surgery for ischemic cardiomyopathy

Introduction and objectivesThere are 2 options to achieve revascularization in ischemic cardiomyopathy: percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). While the benefits of PCI for ischemic cardiomyopathy are unclear, achieving complete revascularization with PCI could improve outcomes comparable to CABG. MethodsA total of 1496 patients with left ventricular ejection fraction (LVEF) <50% and multivessel disease who underwent either PCI or CABG were selected from a single-center cohort registry. They were divided into the PCI with complete revascularization (n=188), the PCI with incomplete revascularization (n=263), and the CABG group (n=1045), and then compared. The primary outcome was a 5-year composite of cardiac death or myocardial infarction. ResultsA total of 1496 patients treated for ischemic cardiomyopathy was stratified into CABG (n=1045) and PCI (n=451) groups, the latter subdivided into complete (n=188) or incomplete revascularization (n=263). PCI showed a higher incidence of the primary outcome compared with CABG (PCI vs CABG, 27.8% vs 22.2%, adjusted HR, 1.35; 95%CI, 1.05-1.73, P=.019). However, PCI with complete revascularization and CABG had similar incidences of the primary outcome (20.5% vs 22.2%, adjusted HR, 1.07; 95%CI, 0.73-1.57; P=.718). ConclusionsCABG is associated with more favorable clinical outcomes than PCI in patients with ischemic cardiomyopathy. However, achieving complete revascularization with PCI could improve outcomes comparable to CABG.

Long-Term Impacts of Complete Revascularization on Clinical Outcomes in Patients with Coronary Chronic Total Occlusion

The impact of complete revascularization (CR), achieved through the recanalization of coronary chronic total occlusions (CTOs), on long-term patient outcomes remains uncertain.To evaluate this in patients who achieved CR after CTO-PCI with those who did not due to deferred CTO-PCI, the Asan Medical Center Registry was reviewed to identify coronary artery disease (CAD) patients with CTOs treated between January 2003 and December 2018. Patients were included with single-vessel disease with CTO and with multivessel disease who had undergone revascularization for non-CTO lesions. These subjects were divided into those who achieved CR with CTO-PCI and those who did not due to deferred CTO-PCI. Their outcomes were compared following 1:1 propensity score matching. Of the 2,746 enrolled CAD patients with CTOs, 1,837 achieved CR with CTO-PCI and 909 did not. Propensity score matching yielded 653 patient pairs. The CR-achieving group had a significantly lower 10-year risk of the primary composite outcome of death, myocardial infarction, stroke, or repeat revascularization (hazard ratio [HR]: 0.57; 95% confidence interval [CI]: 0.46–0.72; P < 0.001), as well as significantly lower risks of death (HR: 0.66; 95% CI: 0.51–0.87; P = 0.003) and repeat revascularization (HR: 0.67; 95% CI: 0.48–0.95; P = 0.023). CR was beneficial in all subgroups, including patients with major cardiovascular risk factors such as older age, hypertension, diabetes, and advanced CAD. Compared with incomplete revascularization, CR may significantly reduce the 10-year incidence of major adverse cardiac events in patients with CTO.

A Comparison Between Culprit Versus Complete Revascularization in Diabetic Patients With Acute Myocardial Infarction.

The benefit of complete revascularization in diabetic patients with myocardial infarction remains unclear. this study aims to find the optimal strategy of total vascular repair for diabetic patients with acute myocardial infarction. In an analysis of a cohort, we assigned diabetic patients with myocardial infarction who were undergoing percutaneous coronary intervention (PCI) of the culprit lesion to receive either staged complete revascularization of nonculprit lesions or to receive no further revascularization in Madani Hospital (Tabriz, Iran). Functionally significant nonculprit lesions were identified either by angiography. The primary outcome was rates of readmission, cardiac deaths, nonfatal myocardial re-infarction, and overall mortality at 1 year. In our center, a total of 1186 patients underwent primary-PCI treatment, among which 521 were diagnosed with diabetes. Ultimately, 393 patients were selected for inclusion in the study. Within this cohort, 271 individuals (68.9%) underwent repair of only the culprit vessels (group 1), while 122 individuals (31.1%) received a comprehensive staged restoration of the vessels (group 2). During this time, group 1 in comparison with group 2 experienced 204 (75.3%) versus 97 (79.5%) cases of readmission, 48 (17.7%) versus 8 (6.5%) instances of cardiac death, 22 (8.1%) versus 18 (14.7%) occurrences of nonfatal myocardial re-infarction. Notably, the incidence of cardiac death in group 2 were significantly lower than that in group 1 (p ≤ 0.05). For individuals diagnosed with diabetes, staged complete revascularization demonstrated a lower frequency of readmission, cardiac deaths, nonfatal myocardial reinfarction, and overall mortality, in contrast to revascularization that targeted only the culprit lesion.

Efficacy of complete versus culprit-lesion only revascularization in patients with diabetes undergoing percutaneous coronary intervention: a pilot meta-analysis

Diabetes is a strong independent predictor of unfavorable cardiovascular outcomes in patients with coronary artery disease, and diabetic patients have a higher prevalence of multivessel disease. The impact of diabetes status on outcomes in patients undergoing complete versus culprit-only revascularization during percutaneous coronary intervention remains unexplored. A comprehensive literature search was conducted using MEDLINE, EMBASE, and SCOPUS. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using a random-effects model in Review Manager (version 5.4), with a P-value of &lt;0.05 considered significant. Five studies comprising a total of 4686 patients met our inclusion criteria. No statistically significant differences were observed between the two groups in terms of all-cause mortality (RR: 0.79; 95% CI: 0.56–1.12; P = 0.19; I 2 = 66%), cardiovascular-related death (RR: 1.12; 95% CI: 0.74–1.69; P = 0.60; I 2 = 29%), myocardial infarction (RR: 0.78; 95% CI: 0.57–1.08; P = 0.13; I 2 = 12%), and stroke (RR: 1.06; 95% CI: 0.52–2.16; P = 0.88; I 2 = 0%).

Immediate Versus Staged Complete Revascularization for Patients With ST-Segment-Elevation Myocardial Infarction and Multivessel Disease: A Network Meta-Analysis of Randomized Trials.

The comparative outcomes with immediate, staged in-hospital, and staged out-of-hospital complete revascularization for patients with ST-segment-elevation myocardial infarction and multivessel disease remain unclear. An electronic search of MEDLINE, SCOPUS, and Cochrane databases was performed through August 2023 for randomized trials evaluating immediate, staged in-hospital, and staged out-of-hospital complete revascularization for patients with ST-segment-elevation myocardial infarction and multivessel disease. The primary outcome was major adverse cardiac events (MACEs). The final analysis included 9 trials with 4270 patients. The weighted follow-up duration was 13.8 months. On pairwise meta-analysis, there were no statistically significant differences between immediate versus staged nonculprit percutaneous coronary intervention (PCI) in MACEs (odds ratio, 0.79 [95% CI, 0.54-1.16]). Network meta-analysis showed that there was no statistically significant difference in MACEs with staged in-hospital nonculprit PCI (odds ratio, 1.29-[95% CI, 0.91-1.82]) compared with immediate nonculprit PCI, while there were higher odds of MACEs with out-of-hospital nonculprit PCI (odds ratio, 1.67-[95% CI, 1.21-2.30]) compared with immediate nonculprit PCI. Compared with immediate nonculprit PCI, there were higher odds of ischemia-driven repeat revascularization with staged out-of-hospital nonculprit PCI (odds ratio, 2.26-[95% CI, 1.37-3.72]), but not with in-hospital staged nonculprit PCI. There were no significant differences for the other outcomes among the 3 strategies. Among patients with ST-segment-elevation myocardial infarction with multivessel disease, an immediate nonculprit PCI approach was associated with similar clinical outcomes to the staged nonculprit PCI approach. The staged out-of-hospital nonculprit PCI approach was associated with a higher incidence of MACEs compared with the other strategies, which was driven by higher risk for ischemia-driven repeat revascularization.

Revascularization strategies in elderly patients with acute coronary syndromes and multivessel disease: comparative analysis of culprit-only vs complete revascularization

Abstract Background Acute coronary syndromes (ACS) are more challenging in elderly patients, particularly when related to multivessel disease (MVD). Concerns about outcomes, and the lack of evidence, lead to more conservative treatment. While benefits of complete revascularization are well established among the youngest, doubts persist in older patients. Despite FIRE trial having showed superiority of complete revascularization with coronary physiology, in older patients with ACS and MVD, more evidence is needed. Methods Multicenter retrospective cohort of 629 patients, older than 75 years, with ACS and MVD, was divided into complete or culprit-only revascularization groups. In-hospital outcome of death and major adverse cardiovascular events (MACE) and follow-up outcome of death and cardiovascular hospital admission were assessed. Results From the 629 patients, 383 (61%) were submitted to PCI, of which 66% (n=254) were submitted to culprit-only revascularization and 34% (n=129) to complete revascularization. Culprit-only group's mean age was 83±5 years and median age in complete revascularization group was 81 (IQ 78-84) years. There was similar number of female patients in both groups (42% and 37%, p=0,26), and the culprit only group was significantly older (p=0,006). There were more ST-segment elevation myocardial infarctions in culprit- only group (p&amp;lt;0,001). Regarding diabetes, previous ACS, Killip classification, heart failure, stroke, peripheral artery disease, and chronic kidney disease, there were no statistically significant differences between groups (p&amp;gt;0,05). Complete revascularization was associated with lower in-hospital events, with 36% against 48% in culprit-only (p=0,025 OR 0,62 [0,4-0,9]), mainly due to lower in-hospital deaths, with 3% against 13% (p&amp;lt;0,01 OR 0,3 [0,15-0,67]) but also due to lower in-hospital MACE with 29% against 27% (p=0,02 OR 0,6 [0,4-0,9]). The mean follow-up was 13±7 months, during which, in complete revascularization group, there was non-statistically significant decrease of deaths, with 13% against 15% (p=0,4), hospital readmissions, with 21,8%, in comparison with 24,9% (p=0,2), and composite outcome, with 35% and 40% (p=0,16) of composite events in the culprit-only group There was a non-statistically significant decrease of the mean for survival time for culprit only group which was 10±8 months comparing with complete group of 13±8 months (p=0,16). Conclusion In older patients with ACS and MVD the ideal strategy is yet to be determined. Still complete revascularization strategy showed a statistically significant decrease of in-hospital death and MACE, and non-statistically significant decrease in follow-up mortality and readmissions. This study suggests, like FIRE trial, that when clinically and anatomically feasible, it seems legit to attempt complete revascularization in elderly patients with ACS and MVD.

Comparison of the prognosis between complete and incomplete revascularization among moderate to severe chronic kidney disease patients with acute coronary syndrome

Abstract Background Complete revascularization (CR) in acute coronary syndrome patients with multivessel disease (MVD) is recommended in current clinical practice guidelines. However, the benefit of CR in moderate to severe chronic kidney disease (CKD) patients remains controversial. We aimed to compare the clinical outcomes between complete and incomplete revascularization among moderate to severe CKD patients who presented with ACS. Methods Of 1,924 ACS patients who underwent percutaneous coronary intervention (PCI) in our center, 127 patients were CKD. CR was defined as residual SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) score ≤ 3. The primary outcome was the patient oriented clinical outcome (POCO) at 1 year, including all-cause death, any myocardial infarction, any revascularization, and heart failure requiring hospitalization. Results The mean age of the patients was 73.89±9.07 years. The median estimated glomerular filtration rate (eGFR) was 32.56±10.68 ml per minute per 1.73 m2. The rate of POCO at 1 year was significantly lower in the CR group (16.3% vs 39.3%; HR 0.36; 95%CI, 0.16-0.81; p=0.014). The primary outcome was mainly driven by 1-year all-cause death which was significantly lower in the CR group (14.0% vs 39.3%; HR 0.32; 95%CI 0.13-0.76; p=0.017). The rate of initiation of renal replacement therapy was comparable (4.7% vs 2.4%; p=0.55). Conclusion CR with a target SYNTAX score ≤ 3 improved 1-year prognosis of POCO and all-cause death in ACS patients with moderate to severe CKD without increasing the rates of renal replacement therapy.1-year POCOPrespecified Subgroup Analysis of POCO

Real-life impact of complete revascularization of non-ST elevation myocardial infarction during index hospitalization

Abstract Introduction patients with non-ST elevation acute myocardial infarction (NSTEMI) frequently present multivessel disease (MVD) with significant stenosis in non-infarct-related arteries (non-IRA). Unlike for ST elevation acute myocardial infarction, there is a paucity of studies evaluating the prognostic impact of complete revascularization in these patients. In fact, recommendation for complete revascularization is based in observational and non-randomized studies suggesting a possible benefit regarding mortality and major cardiovascular events. Purpose to evaluate the prognostic impact of complete revascularization during the index hospitalization in the Portuguese patients with NSTEMI and MVD. Methods patients hospitalized for NSTEMI with MVD included in a national multicentre retrospective study between October 2010 and December 2022 were divided into two groups: group 1 was submitted to complete percutaneous revascularization during the index hospitalization (IRA and non-IRA with diameter stenosis ≥50% on angiography), and group 2 performed IRA-only revascularization. The impact of complete revascularization on the probability of cardiovascular re-hospitalization, as well as on in-hospital and one-year mortality rates was evaluated. Results a total of 3084 patients was included, 74.8% were males, with a mean age of 67.8±11.9 years. Most patients were submitted to IRA-only revascularization (72.9%). From the remaining, 81.4% performed complete revascularization during the index procedure and 18.6% staged during index hospitalization. Group 1 patients were younger (65.5±11.8 vs. 68.6±11.8 years, p&amp;lt;0.001), with fewer comorbidities and slightly higher left ventricular ejection fraction (55±11 vs. 51±11%, p&amp;lt;0.001). On the other hand, group 2 patients revealed a significantly higher percentage of previous, revascularization (14.8% vs. 1.6%), mostly surgical. Besides overall similar incidence of in-hospital complications, including recurrence of acute myocardial infarction, patients submitted to complete revascularization showed a non-significant trend to an inferior in-hospital mortality rate (0.7 vs. 1.6%, p=0.06). Also, 1-year mortality rate was similar between groups (4.2 vs. 5.0%, p=0.54). However, complete revascularization appeared to result in a long-term prognostic benefit, halving the incidence of unplanned cardiovascular re-hospitalizations at one year of follow-up (9.3 vs. 18.8%, p&amp;lt;0.001). Conclusion complete revascularization led to an overall long-term benefit, mainly due to a reduction in cardiovascular re-hospitalizations, without a significant impact on 1-year mortality rate.

Complete vs culprit-lesion-only myocardial revascularization in patients with out-of-hospital cardiac arrest: insights from the multicentric "Lombardia CARe" registry

Abstract Background Out-of-hospital Cardiac Arrest (OHCA) is a potentially devastating complication of patients with Myocardial Infarction (MI). Multivessel Disease (MVD) is a frequent occurrence in this setting, being present in nearly half patients undergoing Coronary Angiography (CAG). We previously reported that, in case of MI complicated by OHCA and evidence of MVD, a complete myocardial revascularization, as compared to culprit-lesion-only revascularization, was associated with an improved 1-year survival and favorable neurological outcomes. We aimed to validate and confirm these results on a multicentric scale with a larger patient cohort. Methods This is a multicentric, prospective, observational study. We considered all the consecutive patients with OHCA and MI enrolled in the Lombardia CARe Registry from January 1st 2015 to December 31st 2022 who underwent CAG in 6 centers in Northen Italy. Results A total of 623 patients were included; of these, 403 underwent CAG. Median age was 64 years, and about 80% had no previous history of ischemic heart disease. Median ejection fraction (EF) at presentation was 40%. MVD was present in 186 (46.1%) patients and was subsequently treated with either complete (32.3%) or incomplete (67.7%) coronary revascularization. Left anterior descendent (LAD) artery was the culprit lesion in almost 1/3 of patients. The 1-year survival rate was 78.3% in the complete revascularization group and 42.9% in the culprit-lesion-only revascularization group (p-value &amp;lt; 0.001). After correction for factors that were predictors on univariate analysis, complete revascularization strategy was independently associated with a reduced risk of death [HR: 0.27 (95% CI: 0.01 to 0.739; p = 0.01] and death or unfavorable neurological outcome [HR: 0.23 (95% CI: 0.08 to 0.67); p = 0.007]. Conclusions Complete revascularization strategy was confirmed to be associated with an improvement of 1-year survival and with a good neurological outcome in patients resuscitated from OHCA. These results highlight the independent impact on survival of a complete coronary intervention strategy in patients with OHCA plus MVD.

Complete revascularisation versus culprit lesion only PCI in patients with non-ST-elevation myocardial infarction and multivessel disease.

Abstract Background The incidence of non-ST-elevation myocardial infarction (NSTEMI) is escalating, with patients diagnosed with multivessel disease (MVD) facing more adverse clinical outcomes. Yet, optimal treatment strategies for NSTEMI patients with MVD remain uncertain. Objectives This study aimed to assess the clinical outcome of NSTEMI patients with MVD who underwent complete revascularization compared to those treated with the culprit lesion only. Methods Between 2014 and 2017, patients presenting with NSTEMI and MVD undergoing successful percutaneous coronary intervention (PCI) were retrospectively included. MVD was defined as patients having more than one lesion considered angiographically significant, exhibiting at least 50% stenosis of the vessel diameter on visual estimation, or having a Coronary Angiography-Derived Fractional Flow Reserve (caFFR) measurement of 0.80 or less. The main exclusion criteria were single vessel disease, and previous coronary-artery bypass grafting surgery. The primary endpoint of this study was major adverse cardiac events (MACE) at 3 years, defined as a composite of cardiac death, myocardial infarction, and ischemia-driven revascularization. Results A total of 358 patients were included (mean age: 67.34±12.77; male: 70.1%), 155 and 203 patients were stratified into complete revascularisation group and culprit-lesion-only PCI group respectively. During 3-year follow-up, the culprit-lesion-only PCI group exhibited a significantly elevated risk of MACE compared to the complete revascularization group (17.7% vs 7.74%; hazard ratio [HR] 2.412, 95% confidence interval [CI] 1.255 - 4.636, P = 0.008). The increase 3-year MACE rate was mainly driven by the higher rate of ischaemia-driven revascularization in the culprit-lesion-only PCI group (11.3% vs 3.23%, HR 3.637, 95% CI 1.383 - 9.566, P = 0.009). Conclusion In NSTEMI patients with MVD, complete revascularization was superior to culprit-lesion-only PCI in mitigating the risk of future MACE at 3 years, which is predominantly attributed by a reduced incidence of repeat revascularisations.

Clinical outcomes of immediate complete versus staged revascularization among STEMI patients and multivessel disease without cardiogenic shock: a meta-analysis

Abstract Introduction Multivessel disease in STEMI patients uncomplicated by cardiogenic shock is associated with adverse prognosis and recent evidence support complete revascularization in these patients. However, the optimal timing of non-culprit lesion revascularization is still debated. Methods A literature search from PubMed, Cochrane and Embase databases for relevant RCTs published until December 2023 were conducted. The main outcomes of interests were all-cause mortality, re-infarction, and target vessel revascularization. Results The search yielded 4 randomized controlled trials and the total number of patients included was 1,137 (immediate complete = 571; staged revascularization = 566). Our pooled estimated showed that immediate complete revascularization in STEMI patients and multivessel disease without cardiogenic shock, compared to staged revascularization, was associated with lower rates of re-infarction (OR 0.51, 95% CI 0.27 – 0.98, p &amp;lt; 0.04, I2=22%) and target vessel revascularization (OR 0.54, 95% CI 0.33 – 0.87. p = 0.01, I2=21%), with no significant difference in terms of all-cause mortality (OR 1.22, 95% CI 0.69-2.16, p &amp;lt;0.5, I2=0%). Conclusion In STEMI patients and multivessel disease without cardiogenic shock, immediate complete revascularization is associated with better outcomes in terms of reducing the rate of reinfarction and target vessel revascularization, while there was no significant difference in the outcomes of all-cause mortality between the two groups. These results challenge the current guidelines which favors staged PCI than an immediate complete revascularization approach.Abstract summary poster

Prognostic impact of the extent of coronary artery disease in patients with acute transmural myocardial infarction undergoing complete percutaneous revascularization

Abstract Background The management of acute myocardial infarction has been revolutionised by the introduction of early coronary angiography and the reperfusion strategies. Recent studies support the standard of care of complete myocardial revascularization in all patients with ST-elevation myocardial infarction (STEMI) without assessing the prognostic role of the extent of coronary artery disease (CAD). Purpose To evaluate whether the extent of CAD in patients with STEMI has a prognostic impact independent of complete myocardial revascularization. Methods Observational cohort study of 365 patients with STEMI who underwent complete revascularization. For each patient the extent of CAD has been quantified using Gensini Score (GS), which takes into account both the severity and location of the lesions. The primary endpoint of the study was all-cause mortality, while cardiovascular mortality and a composite of major adverse cardiovascular events (MACE: cardiovascular mortality, recurrent acute myocardial infarction or myocardial revascularization and stroke) were defined as secondary endpoints. To assess the prognostic role of GS in predicting all-cause mortality, the area under the curve (AUC) was calculated. The best cut-off was determined as the one that maximized Youden's index (sensitivity + specificity - 1). Results Patients with a GS &amp;gt;80, indicating extensive coronary disease, had significantly higher rates of both cardiovascular [4 (16.7%) vs. 12 (3.5%); p = 0.002] and all-cause mortality [5 (20.8%) vs. 24 (7%); p = 0.016], than those with a GS ≤80. A GS &amp;gt;80 was demonstrated to be an independent predictor of all-cause mortality [hazard ratio = 5; 95% confidence interval: 1.5-16.8; p = 0.01] Conclusions The Gensini Score can identify high-risk patients with STEMI who may benefit from more intensive therapies to improve prognosis, although current guidelines do not specify treatment based on the extent of coronary disease.Long-term outcomes according to GSPrognostic value of GS