Culprit-only Revascularization Research Articles

Culprit-Only Revascularization, Single-Setting Complete Revascularization, and Staged Complete Revascularization in Acute Myocardial Infarction: Insights From a Mixed Treatment Comparison Meta-Analysis of Randomized Trials.

Complete revascularization improves cardiovascular outcomes compared with culprit-only revascularization in patients with acute myocardial infarction ([MI]; ST-segment-elevation MI or non-ST-segment-elevation MI) and multivessel coronary artery disease. However, the timing of complete revascularization (single-setting versus staged revascularization) is uncertain. The aim was to compare the outcomes of single-setting complete, staged complete, and culprit vessel-only revascularization in patients with acute MI and multivessel disease. PubMed, EMBASE, and clinicaltrials.gov databases were searched for randomized controlled trials that compared 3 revascularization strategies. From 16 randomized controlled trials that randomized 11 876 patients with acute MI and multivessel disease, both single-setting complete and staged complete revascularization reduced primary outcome (cardiovascular mortality/MI; odds ratio [OR], 0.52 [95% CI, 0.41-0.65]; OR, 0.74 [95% CI, 0.62-0.88]), composite of all-cause mortality/MI (OR, 0.52 [95% CI, 0.40-0.67]; OR, 0.78 [95% CI, 0.67-0.91]), major adverse cardiovascular event (OR, 0.42 [95% CI, 0.32-0.56]; OR, 0.62 [95% CI, 0.47-0.82]), MI (OR, 0.39 [95% CI, 0.26-0.57]; OR, 0.73 [95% CI, 0.59-0.90]), and repeat revascularization (OR, 0.30 [95% CI, 0.18-0.47]; OR, 0.46 [95% CI, 0.30-0.71]) compared with culprit-only revascularization. Single-setting complete revascularization reduced cardiovascular mortality/MI (OR, 0.70 [95% CI, 0.55-0.91]), major adverse cardiovascular event (OR, 0.67 [95% CI, 0.50-0.91]), and all-cause mortality/MI driven by a lower risk of MI (OR, 0.53 [95% CI, 0.36-0.77]) compared with staged complete revascularization. Single-setting complete revascularization ranked number 1, followed by staged complete revascularization (number 2) and culprit-only revascularization (number 3) for all outcomes. The results were largely consistent in subgroup analysis comparing ST-segment-elevation MI versus non-ST-segment-elevation MI cohorts. Single-setting complete revascularization may offer the greatest reductions in cardiovascular events in patients with acute MI and multivessel disease. A large-scale randomized trial of single-setting complete versus staged complete revascularization is warranted to evaluate the optimal timing of complete revascularization.

Managing the Intricacies of Coronary Revascularization: A Close Look at the Complete Versus Culprit-Only Approach and its Implications in Elderly Patients.

Coronary heart disease is the leading cause of mortality in the United States, and data indicates that 805,000 Americans will face a new or recurrent myocardial infarction (MI) attack every year. Frailty, a conceptual syndrome categorized by a functional decline that occurs with aging, has been linked to adverse health outcomes in cardiovascular disease and all cardiac-related procedures in general. It is therefore reasonable to deliberate that more conservative medical therapy or medical management should be considered in the frail population when managing acute coronary syndrome. This course of action has, in fact, been documented in clinical practice. However, the recent Functional Assessment in Elderly MI Patients with Multivessel Disease trial, in which all subjects were 75 years of age or above, indicated that the more invasive complete revascularization approach may be favorable over incomplete or culprit-only revascularization in patients with acute MI. In this review, we will discuss coronary heart disease and review guidelines and procedures for culprit lesion identification, including electrocardiogram procedures, coronary angiography, intravascular ultrasound, fractional flow reserve, and instantaneous fractional flow reserve. We then discuss the concept of complete vs culprit-only/incomplete coronary revascularization and staging. Following this, we will delve into recent trials discussing complete vs culprit-only revascularization, emphasizing the insights gleaned from this latest trial within this special frailty cohort which warrants special consideration.

Health-Status Outcomes in Older Patients With Myocardial Infarction: Physiology-Guided Complete Revascularization Versus Culprit-Only Strategy.

The FIRE trial (Functional Assessment in Elderly Myocardial Infarction Patients With Multivessel Disease) enrolled 1445 older (aged ≥75 years) patients with myocardial infarction and multivessel disease in Italy, Spain, and Poland. Patients were randomized to physiology-guided complete revascularization or treatment of the only culprit lesion. Physiology-guided complete revascularization significantly reduced ischemic adverse events at 1 year. This prespecified analysis investigated the changes between the 2 study groups in angina status, quality of life, physical performance, and frailty. Patients underwent validated scales at hospital discharge (baseline) and 1 year later. Angina status was evaluated using the Seattle Angina Questionnaire, health-related quality of life by EQ visual analog scale, physical performance by short physical performance battery, and frailty by the clinical frailty scale. Mixed models for repeated measures analysis were used to study the association between the treatment arms, time, and scales. Baseline and 1-year Seattle Angina Questionnaire, EQ visual analog scale, short physical performance battery, and clinical frailty scale were collected in around two-thirds of the entire FIRE study population. The mean age was 80.9±4.6 years (female sex, 35.9%). Overall, 35.3% were admitted for ST-segment-elevation myocardial infarction, whereas the others were admitted for non-ST-segment-elevation myocardial infarction. Physiology-guided complete revascularization, compared with culprit-only revascularization, was associated with greater improvement in terms of angina status (Seattle Angina Questionnaire summary score, 7.3 [95% CI, 6.1-8.6] points), health-related quality of life (EQ visual analog scale, 6.2 [95% CI, 4.4-8.1] points), and physical performance (short physical performance battery, 1.1 [95% CI, 0.9-1.3] points). After 1 year, patients randomized to culprit-only revascularization experienced a deterioration in frailty status (clinical frailty scale, 0.2 [95% CI, 0.1-0.3] points), which was not observed in patients randomized to physiology-guided complete revascularization. The present analysis suggested that a physiology-guided complete revascularization is associated with consistent benefits in terms of angina status, quality of life, physical performance, and the absence of further deterioration of the frailty status. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03772743.

Complete versus partial revascularization for older adults with acute coronary syndrome: a meta-analysis and systematic review of randomized and multivariable adjusted data.

Evidence from randomized studies support complete over culprit-only revascularization for patients with acute coronary artery syndrome (ACS) and multivessel coronary artery diseases (MVD). Whether these findings extend to elderly patients, however, has not been thoroughly explored. We conducted a systematic review and meta-analysis comparing clinical outcomes of elderly individuals (defined as age ≥75 years) with ACS and MVD submitted to complete vs partial-only percutaneous coronary intervention (PCI). PubMed, Embase, and Cochrane were searched. We computed pooled hazard ratios with 95% confidence intervals (CI) to preserve time time-to-event data. We included 7 studies, of which 2 were RCT and 5 were multivariable adjusted cohorts, comprising a total 10 147, of whom 43.8% underwent complete revascularization. As compared with partial-only PCI, complete revascularization was associated with a lower all-cause mortality (hazard ratio 0.71; 95% CI 0.60-0.85; P < 0.01), cardiovascular mortality (hazard ratio 0.64; 95% CI 0.52-0.79; P < 0.01), and recurrent myocardial infarction (hazard ratio 0.65; 95% CI 0.50-0.85; P < 0.01). There was no significant difference between groups regarding the risk of revascularizations (hazard ratio 0.80; 95% CI 0.53-1.20; P = 0.28). Among elderly patients with ACS and multivessel CAD, complete revascularization is associated with a lower risk of all-cause mortality, cardiovascular mortality, and recurrent myocardial infarction.

QFR for the Revascularization of Nonculprit Vessels in MI Patients: Insights From the FIRE Trial.

The role of quantitative flow ratio (QFR) in the treatment of nonculprit vessels of patients with myocardial infarction (MI) is a topic of ongoing discussion. This study aimed to investigate the predictive capability of QFR for adverse events and its noninferiority compared to wire-based functional assessment in nonculprit vessels of MI patients. The FIRE (Functional Assessment in Elderly MI Patients With Multivessel Disease) trial randomized 1,445 older MI patients to culprit-only (n=725) or physiology-guided complete revascularization (n=720). In the culprit-only arm, angiographic projections of nonculprit vessels were prospectively collected, centrally reviewed for QFR computation, and associated with endpoints. In the complete revascularization arm, endpoints were compared between nonculprit vessels investigated with QFR or wire-based functional assessment. The primary endpoint was the vessel-oriented composite endpoint (VOCE) at 1 year. QFR was measured on 903 nonculprit vessels from 685 patients in the culprit-only arm. Overall, 366 (40.5%) nonculprit vessels showed a QFR value≤0.80, with a significantly higher incidence of VOCEs (22.1% vs 7.1%; P< 0.001). QFR≤0.80 emerged as an independent predictor of VOCEs (HR: 2.79; 95%CI: 1.64-4.75). In the complete arm, QFR was used in 320 (35.2%) nonculprit vessels to guide revascularization. When compared with propensity-matched nonculprit vessels in which treatment was guided by wire-based functional assessment, no significant difference was observed (HR:0.57; 95%CI: 0.28-1.15) in VOCEs. This prespecified subanalysis of the FIRE trial provides evidence supporting the safety and efficacy of QFR-guided interventions for the treatment of nonculprit vessels in MI patients. (Functional Assessment in Elderly MI Patients With Multivessel Disease [FIRE]; NCT03772743).

Complete vs Culprit-Only Revascularization in Older Patients With Myocardial Infarction and High Bleeding Risk

Patients with high bleeding risk (HBR) have a poor prognosis, and it is not known if they may benefit from complete revascularization after myocardial infarction (MI). To investigate the benefit of physiology-guided complete revascularization vs a culprit-only strategy in patients with HBR, MI, and multivessel disease. This was a prespecified analysis of the Functional Assessment in Elderly MI Patients With Multivessel Disease (FIRE) randomized clinical trial data. FIRE was an investigator-initiated, open-label, multicenter trial. Patients 75 years or older with MI and multivessel disease were enrolled at 34 European centers from July 2019 through October 2021. Physiology treatment was performed either by angiography- or wire-based assessment. Patients were divided into HBR or non-HBR categories in accordance with the Academic Research Consortium HBR document. Patients were randomized to either physiology-guided complete revascularization or culprit-only strategy. The primary outcome comprised a composite of death, MI, stroke, or revascularization at 1 year. Secondary outcomes included a composite of cardiovascular death or MI and Bleeding Academic Research Consortium (BARC) types 3 to 5. Among 1445 patients (mean [SD] age, 81 [5] years; 917 male [63%]), 1025 (71%) met HBR criteria. Patients with HBR were at higher risk for the primary end point (hazard ratio [HR], 2.01; 95% CI, 1.47-2.76), cardiovascular death or MI (HR, 1.89; 95% CI, 1.26-2.83), and BARC types 3 to 5 (HR, 3.28; 95% CI, 1.40-7.64). The primary end point was significantly reduced with physiology-guided complete revascularization as compared with culprit-only strategy in patients with HBR (HR, 0.73; 95% CI, 0.55-0.96). No indication of interaction was noted between revascularization strategy and HBR status for primary and secondary end points. HBR status is prevalent among older patients with MI, significantly increasing the likelihood of adverse events. Physiology-guided complete revascularization emerges as an effective strategy, in comparison with culprit-only revascularization, for mitigating ischemic adverse events, including cardiovascular death and MI. ClinicalTrials.gov Identifier: NCT03772743.

Clinical Significance of Residual Ischemia in Acute Myocardial Infarction Complicated by Cardiogenic Shock Undergoing VA-ECMO.

Although culprit-only revascularization during the index procedure has been recommended in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS), the reduction of residual ischemia is also emphasized to improve clinical outcomes. However, few data are available about the significance of residual ischemia in patients undergoing mechanical circulatory supports. This study aimed to evaluate the effects of residual ischemia on clinical outcomes in AMI patients undergoing venoarterial-extracorporeal membrane oxygenation (VA-ECMO). AMI patients with multivessel disease who underwent VA-ECMO due to refractory CS were pooled from the RESCUE and SMC-ECMO registries. The included patients were classified into three groups according to residual ischemia evaluated using the residual SYNTAX score (rSS): rSS = 0, 0 < rSS ≤ 8, and rSS > 8. The primary outcome was 1-year all-cause death. A total of 408 patients were classified into the rSS = 0 (N = 100, 24.5%), 0 < rSS ≤ 8 (N = 136, 33.3%), and rSS > 8 (N = 172, 42.2%) groups. The cumulative incidence of the primary outcome differed significantly according to rSS (33.9% vs. 55.4% vs. 66.1% for rSS = 0, 0 < rSS ≤ 8, and rSS > 8, respectively, overall P < 0.001). In a multivariable model, rSS was independently associated with the risk of 1-year all-cause death (HRadj 1.03, 95% CI 1.01-1.05, P = 0.003). Conversely, the baseline SYNTAX score was not associated with the risk of the primary outcome. Furthermore, when patients were stratified by rSS, the primary outcome did not differ significantly between the high and low delta SYNTAX score groups. In AMI patients with refractory CS who underwent VA-ECMO, residual ischemia was associated with an increased risk of 1-year mortality. Future studies are needed to evaluate the efficacy and safety of revascularization strategies to minimize residual ischemia in patients with CS supported with VA ECMO. REtrospective and Prospective Observational Study to Investigate Clinical oUtcomes and Efficacy of Left Ventricular Assist Device for Korean Patients With Cardiogenic Shock (RESCUE), NCT02985008.

Fractional Flow Reserve and Angiography Guided Complete Revascularization in Primary Percutaneous Coronary Intervention: A Systematic Review and Network Meta-Analysis.

Using a network meta-analysis, this study compared fractional flow reserve (FFR) guided with angiography-guided revascularization of non-culprit lesions in ST elevation myocardial infarction (STEMI). We also assessed if early complete revascularization is superior to delayed revascularization. We conducted a network meta-analysis using Net Meta XL of trials of STEMI patients with multivessel disease and compared revascularization strategies. The primary outcomes of interest were rate of revascularization, myocardial infarction, and all-cause mortality. Ten studies were included in our analysis comprising 7981 patients with 4484 patients undergoing complete revascularization and 3497 patients with culprit-only revascularization. There was no significant reduction in all-cause death, myocardial infarction, or revascularization using FFR guidance. There was significant reduction in repeat revascularization with complete revascularization irrespective of timing of percutaneous coronary intervention (PCI) compared with the culprit-only group. There was an overall trend favoring earlier revascularization. For patients with multivessel disease presenting with ST-elevation MI, complete revascularization significantly reduces repeat revascularization compared with culprit-only treatment. FFR guidance is non-superior to angiography-guided revascularization. Furthermore, there was significant reduction in repeat revascularization irrespective of timing of PCI to non-culprit vessels.

Updated Strategies in Non-Culprit Stenosis Management of Multivessel Coronary Disease-A Contemporary Review.

The prevalence of multivessel coronary artery disease (CAD) in acute coronary syndrome (ACS) patients underscores the need for optimal revascularization strategies. The ongoing debate surrounding percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), hybrid interventions, or medical-only management adds complexity to decision-making, particularly in specific angiographic scenarios. The article critically reviews existing literature, providing evidence-based perspectives on non-culprit lesion revascularization in ACS. Emphasis is placed on nuances such as the selection of revascularization methods, optimal timing for interventions, and the importance of achieving completeness in revascularization. The debate between culprit-only revascularization and complete revascularization is explored in detail, focusing on ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI), including patients with cardiogenic shock. Myocardial revascularization guidelines and recent clinical trials support complete revascularization strategies, either during the index primary PCI or within a short timeframe following the culprit lesion PCI (in both STEMI and NSTEMI). The article also addresses the complexities of decision-making in NSTEMI patients with multivessel CAD, advocating for immediate multivessel PCI unless complex coronary lesions require a staged revascularization approach. Finally, the article provided contemporary data on chronic total occlusion revascularization in ACS patients, highlighting the prognostic impact. In conclusion, the article addresses the evolving challenges of managing multivessel CAD in ACS patients, enhancing thoughtful integration into the clinical practice of recent data. We provided evidence-based, individualized approaches to optimize short- and long-term outcomes. The ongoing refinement of clinical and interventional strategies for non-culprit lesion management remains dynamic, necessitating careful consideration of patient characteristics, coronary stenosis complexity, and clinical context.

Abstract 16866: Complete Revascularization for Left Main Acute Myocardial Infarction

Background: In patients presenting with acute myocardial infarction (AMI) with left main (LM) culprit lesion and multivessel disease, percutaneous coronary intervention (PCI) of non-culprit lesions in LM culprit AMI is challenging and whether it reduces mortality and adverse events is unclear. Hypothesis: Complete revascularization will show better outcome than culprit-only revascularization in multi-vessel LM AMI PCI. Methods: We reviewed total of 16831 patients among from July 2016 to June 2020 Korean Acute Myocardial Infarction Registry (KAMIR) and 395 patients were enrolled with LM culprit multi-vessel AMI treated by PCI. We excluded in-hospital death 35 cases then categorized patients whether treated with complete revascularization (n=198) or culprit-only revascularization (n=162). Study outcome was a composite of major cardiac adverse events (MACE) including cardiac death, myocardial infarction, re-PCI, stent thrombosis and rehospitalization due to heart failure. We used propensity score (PS) matching method and cumulative event-free survival and MACE were analyzed over 3 years follow-up. Results: After PS matching, baseline and angiographic characteristics were similar between two groups (Complete group, n=142 versus Culprit-only group, n=142). Killip classification (Class IV : n=13 (9.2%) versus n=14 (9.9%), p -value=0.762) and initial diagnosis (STEMI : n=47 (33.1%) versus n=52 (36.6%), p- value=0.618) at admission were also not different between two groups. There was no difference in MACE between two groups (n=27 (19%) versus n=28 (19.7%), log-rank test p- value = 0.64). Conclusion: Although, other studies had shown better outcome of complete revascularization in multi-vessel AMI, in multi-vessel LM AMI PCI, complete revascularization should be carefully decided depending on the patient's condition.

Abstract 15875: Immediate Complete Revascularization Reduces Recurrent Myocardial Infarction and Repeat Revascularization in Patients Presenting With Acute Myocardial Infarction

Introduction: Studies have suggested that complete revascularization has better outcome compared with culprit-only revascularization for the treatment of enzyme-positive acute coronary syndrome. However, the optimal timing of complete revascularization remains unclear. We conducted a meta-analysis of randomized controlled trials (RCT) comparing immediate complete revascularization with staged revascularization in patients with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI) with multi-vessel disease. Methods: We systematically searched the Cochrane Central Register of Controlled Trials, Embase, PubMed and clinicaltrials.gov databases for RCT comparing immediate complete revascularization with staged revascularization in patients with enzyme-positive acute coronary syndrome. The pooled outcome were major cardiovascular adverse event (MACE), all-cause death, cardiovascular death, recurrent MI and repeat revascularization. The random effect and Mantel-Haenszel method was used to analyze the data. Heterogeneity was measured using I 2 . Results: Five studies met the inclusion criteria ( 1187 patients in immediate complete revascularization group and 1176 patients in staged revascularization group). We did not find any significant difference in the rate of MACE (OR: 0.75 [95 % CI: 0.44-1.29] I 2 : 35%, p value = 0.30). Similarly, there was no significant difference in the rates of all-cause death (OR: 0.93 [95 % CI: 0.47-1.86] I 2 : 40%, p value = 0.84)and cardiac death (OR: 1.02 [95 % CI: 0.52-1.98] I 2 : 14%, p value = 0.96). However, immediate complete revascularization group had significant reduction in the rates of repeat revascularization (OR: 0.59 [95 % CI: 0.43-0.82] I 2 : 0%, p value = 0.002) and recurrent MI (OR: 0.52 [95 % CI: 0.32-0.84] I 2 : 1%, p value = 0.008). Subgroup analysis including STEMI patients only showed similar rate of MACE ((OR: 0.92 [95 % CI: 0.60-1.41] I 2 : 0%, p value = 0.70). Conclusions: Our results suggest that immediate complete revascularization is safe. There was significant reduction in recurrent MI and need for repeat revascularization in patients undergoing immediate complete revascularization.

Renal Impact of Culprit-Only versus Multi-Vessel Revascularization for Cardiogenic Shock Complicating Acute Myocardial Infarction: Systematic Review and Meta-Analysis.

The optimal strategy of percutaneous coronary intervention (PCI) for acute myocardial infarction (MI) complicated with cardiogenic shock (CS) remains controversial. We aimed to elucidate the renal and cardiovascular impact of culprit-only (C) revascularization versus additional interventions on non-infarct-related arteries. PubMed, Embase, MEDLINE, and Cochrane Library were searched for relevant literature. A total of 96,812 subjects [C-PCI: 69,986; multi-vessel (MV)-PCI: 26,826] in nine studies (one randomized control trial; eight observational cohort studies) were enrolled. MV-PCI was associated with a higher kidney event rate [relative risk (RR): 1.29, 95% confidence interval (CI): 1.12-1.49; p < 0.001]. However, the all-cause mortality rate was comparable both during admission (RR: 1.07, 95% CI: 0.94-1.22; p = 0.30) and at one year (RR: 0.96, 95% CI: 0.79-1.16; p = 0.65). MV-PCI was associated with a greater risk of stroke (RR: 1.19, 95% CI: 1.08-1.32; p < 0.001) and bleeding events (RR: 1.27, 95% CI: 1.07-1.51; p = 0.006), but reduced risk of recurrent MI (RR: 0.89, 95% CI: 0.82-0.97; p = 0.009) and repeat revascularization (RR: 0.34, 95% CI: 0.16-0.71; p = 0.004). No increased risk of coronary artery bypass grafting was present (RR: 1.09, 95% CI: 0.38-3.17; p = 0.87). C-PCI was associated with a lower rate of renal dysfunction but not all-cause mortality in patients with CS complicating acute MI.

Complete Revascularization Versus Culprit-Lesion-Only PCI in STEMI Patients With Diabetes and Multivessel Coronary Artery Disease: Results From the COMPLETE Trial.

In the COMPLETE trial (Complete Versus Culprit-Only Revascularization to Treat Multivessel Disease After Early PCI for STEMI), a strategy of complete revascularization reduced the risk of major cardiovascular events compared with culprit-lesion-only percutaneous coronary intervention in patients presenting with ST-segment-elevation myocardial infarction (STEMI) and multivessel coronary artery disease. Patients with diabetes have a worse prognosis following STEMI. We evaluated the consistency of the effects of complete revascularization in patients with and without diabetes. The COMPLETE trial randomized a strategy of complete revascularization, consisting of angiography-guided percutaneous coronary intervention of all suitable nonculprit lesions, versus a strategy of culprit-lesion-only percutaneous coronary intervention (guideline-directed medical therapy alone). In prespecified analyses, treatment effects were determined in patients with and without diabetes on the first coprimary outcome of cardiovascular death or new myocardial infarction and the second coprimary outcome of cardiovascular death, new myocardial infarction, or ischemia-driven revascularization. Interaction P values were calculated to evaluate whether there was a differential treatment effect in patients with and without diabetes. Of the 4041 patients enrolled in the COMPLETE trial, 787 patients (19.5%) had diabetes. The median HbA1c (glycated hemoglobin) was 7.7% in the diabetes group and 5.7% in the nondiabetes group. Complete revascularization consistently reduced the first coprimary outcome in patients with diabetes (hazard ratio, 0.87 [95% CI, 0.59-1.29]) and without diabetes (hazard ratio, 0.70 [95% CI, 0.55-0.90]), with no evidence of a differential treatment effect (interaction P=0.36). Similarly, for the second coprimary outcome, no differential treatment effect (interaction P=0.27) of complete revascularization was found in patients with diabetes (hazard ratio, 0.61 [95% CI, 0.43-0.87]) and without diabetes (hazard ratio, 0.48 [95% CI, 0.39-0.60]). Among patients presenting with STEMI and multivessel disease, the benefit of complete revascularization over a culprit-lesion-only percutaneous coronary intervention strategy was consistent regardless of the presence or absence of diabetes.

Propensity Matched Comparison of Clinical Outcome After Immediate Versus Staged Complete Revascularization in Patients With Acute Coronary Syndrome and Multivessel Disease

Complete revascularization (CR) in patients with acute coronary syndromes (ACS) and multivessel disease (MVD) improves clinical outcomes compared with culprit-only revascularization, but the optimal timing for non-culprit lesions treatment remains unclear. This study evaluated patients presenting with ACS and MVD admitted between January 2015 and September 2021 at the Erasmus University Medical Center. Clinical outcomes were compared between immediate and staged CR in terms of major adverse cardiac and cerebrovascular events (MACCEs), a composite of all-cause mortality, myocardial infarction, stroke, and any unplanned revascularization. A total of 1,400 patients presenting with ACS and MVD who underwent immediate or staged CR were included in this study. Using 1/many propensity score matching without replacement, 299 patients in the staged CR group were matched to 598 patients in the immediate CR group (mean 1:2 ratio), rendering a total of 897 patients for analysis. The median follow-up period was 648days. MACCE rate was significantly higher in the staged CR group than in the immediate CR group (adjusted hazard ratio [95% confidence interval] 1.60 [1.05 to 2.45], p=0.03). Furthermore, number of stents, stent length, and contrast usage were significantly greater in the staged revascularization group. Immediate CR was associated with less risk of MACCE than was staged CR. Staged CR required overall more contrast and stent material.

Thirty-day outcomes of in-hospital multi-vessel versus culprit-only revascularization strategy for ST-segment elevation myocardial infarction with multivessel coronary disease.

Many studies have demonstrated the benefit of complete multivessel revascularization versus culprit-only intervention in patients of ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease. However, only a few single-center retrospective studies were performed on small Chinese cohorts. Our study aims to demonstrate the advantage of multivessel percutaneous intervention (PCI) strategy on 30-day in-hospital outcomes to patients with STEMI and multivessel disease in larger Chinese population. From the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome (CCC-ACS) project, 5935 patients with STEMI and multivessel disease undergoing PCI and hospitalized for fewer than 30 days were analyzed. After 5: 1 propensity score matching, 3577 patients with culprit-only PCI and 877 with in-hospital multivessel PCI were included. The primary outcome was major adverse cardiovascular and cerebrovascular event (MACCE), defined as a composite of myocardial infarction, all-cause death, stent thrombosis, heart failure, and stroke. Multivariable logistic regression analysis revealed that in-hospital multivessel PCI was associated with lower risk of 30-day MACCE (adjusted OR = 0.75, 95% CI: 0.57-0.98, P = 0.032) than culprit-only PCI and conferred no increased risk of all-cause death, myocardial infarction, stent thrombosis, stroke, or bleeding. Subgroup analysis showed that MACCE reduction was observed more often from patients with trans-femoral access (OR = 0.34, 95% CI: 0.15-0.74) than with trans-radial access (OR = 0.87, 95% CI: 0.66-1.16, P for interaction = 0.017). The in-hospital multivessel PCI strategy was associated with a lower risk of 30-day MACCE than culprit-only PCI in patients with STEMI and multivessel coronary artery disease.

Complete revascularization is associated with higher mortality in patients with ST-elevation myocardial infarction, multi-vessel disease and shock defined by hyperlactataemia: results from the Harefield Shock Registry incorporating explainable machine learning.

Revascularization strategy for patients with ST-elevation myocardial infarction (STEMI) and multi-vessel disease varies according to the patient's cardiogenic shock status, but assessing shock acutely can be difficult. This article examines the link between cardiogenic shock defined solely by a lactate of ≥2 mmol/L and mortality from complete vs. culprit-only revascularization in this cohort. Patients presenting with STEMI, multi-vessel disease without severe left main stem stenosis and a lactate ≥2 mmol/L between 2011 and 2021 were included. The primary endpoint was mortality at 30 days by revascularization strategy for shocked patients. Secondary endpoints were mortality at 1 year and over a median follow-up of 30 months. Four hundred and eight patients presented in shock. Mortality in the shock cohort was 27.5% at 30 days. Complete revascularization (CR) was associated with higher mortality at 30 days [odds ratio (OR) 2.1 (1.02-4.2), P = 0.043], 1 year [OR 2.4 (1.2-4.9), P = 0.01], and over 30 months follow-up [hazard ratio (HR) 2.2 (1.4-3.4), P < 0.001] compared with culprit lesion-only percutaneous coronary intervention (CLOP). Mortality was again higher in the CR group after propensity matching (P = 0.018) and inverse probability treatment weighting [HR 2.0 (1.3-3.0), P = 0.001]. Furthermore, explainable machine learning demonstrated that CR was behind only blood gas parameters and creatinine levels in importance for predicting 30-day mortality. In patients presenting with STEMI and multi-vessel disease in shock defined solely by a lactate of ≥2 mmol/L, CR is associated with higher mortality than CLOP.

Culprit-only versus immediate multi-vessel revascularization in patients with AMI complicated by advanced cardiogenic shock undergoing VA-ECMO

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): This study was supported by unrestricted grants from the Korean Society of Interventional Cardiology. Aims Despite the benefit of culprit-only percutaneous coronary intervention (PCI) in the CULPRIT-SHOCK trial, the optimal revascularization strategy for a refractory cardiogenic shock (CS) requiring mechanical circulatory support devices remains controversial. This study aimed to compare clinical outcomes between the culprit-only and immediate multi-vessel PCI strategies in patients with acute myocardial infarction (AMI) complicated by CS who underwent venoarterial-extracorporeal membrane oxygenation (VA-ECMO). Methods and Results This study was patient-pooled data from the RESCUE and SMC-ECMO registries. A total of 408 AMI patients with multi-vessel disease who underwent VA-ECMO due to refractory CS were included in this analysis. The study population was classified into culprit-only versus immediate multi-vessel PCI according to non-culprit lesion (NCL) treatment strategies. The co-primary endpoints were 30-day mortality or renal-replacement therapy and 12-month follow-up mortality. Among the study population, 241 (59.1%) underwent culprit-only PCI and 167 (40.9%) underwent immediate multi-vessel PCI. Compared with culprit-only PCI, immediate multi-vessel PCI was associated with significantly lower risks of 30-day mortality or renal-replacement therapy (66.8% vs. 54.5%, p=0.02) and all-cause mortality during 12 months of follow-up (59.5% vs. 47.8%, hazard ratio [HR] 0.70; 95% confidence interval [CI] 0.53–0.92, p=0.01) in patients with AMI and CS who underwent VA-ECMO. These results were also consistent in the 290 pairs of propensity score-matched population (55.6% vs. 46.1%, HR 0.71; 95% CI 0.51–0.98, p=0.04). Conclusion Among AMI patients with multi-vessel disease complicated by advanced CS, immediate multi-vessel PCI might be associated with improved clinical outcomes in those undergoing VA-ECMO.

Remote vessels vs culprit-only angioplasty in ST-segment elevation myocardial infarction: reinfarction and all-cause mortality

Abstract Funding Acknowledgements Type of funding sources: None. Background and purpose In ST-segment elevation myocardial infarction (STEMI) patients with multivessel coronary artery disease (MVCAD), remote-vessel percutaneous coronary intervention (PCI) has been associated with a reduction in the incidence of reinfarction when compared to a culprit-only revascularization strategy. Overall effects on long-term all-cause mortality are still unclear. Methods Between 2008 and 2013, a total of 584 consecutive patients were admitted with STEMI. 535 survived to discharge, from which 302 (56,5%) had MVCAD and were included in the analysis. We stratified the patients according to the revascularization strategy in two groups: culprit-lesion-only PCI and PCI of non-culprit vessels with angiographic significant stenosis. Patients were followed for 8 years. The primary endpoints were reinfarction in any vessel and all-cause death. Secondary endpoints included target vessel failure (TVF) (any repeat revascularization in the index culprit vessel), heart failure (HF) hospitalization and stroke. Results Of the 302 cases, 217 (74.2%) were men and the median age was 63 years. 150 (49.7%) had 2-vessel, 152 (50.3%) had 3-vessel disease and 104 (34.4%) underwent non-culprit vessel PCI. The mean follow-up time was 6.95 (± 2.29) years. Overall, the culprit-lesion-only group was older (median: 66 vs 59.5 years; p &amp;lt; 0.001) and had a lower proportion of smokers (41.9% vs 59.6%; p = 0.003). There were no significant differences between the groups’ other main comorbidities. The culprit-lesion-only group had a shorter hospital stay (median: 7.0 vs 7.5; p = 0.013), despite presenting at higher Killip class (24.4% vs 10.6% in Killip II-IV; p = 0.004). Regarding index PCI, no-reflow phenomenon was more common in the culprit-lesion-only group (7.1% vs 1.0%; p = 0.020), where the use of drug-eluted stents was more prevalent in the remote-vessel PCI group (69.2% vs 47.0%; p = 0.001). There was a higher risk of reinfarction (Adjusted hazard ratio (HR) 2.46; 95% CI [1.12 – 5.38]; p = 0.008) and TVF (Adjusted HR 2.37; 95% CI [1.02 – 5.48]; p = 0.044) in the culprit-lesion-only PCI group after relevant variable adjustment, with no significant differences in all-cause mortality. There were no significant differences in any of the remaining secondary outcomes. Conclusions Randomized trials and successive metanalysis have demonstrated benefit in complete revascularization after STEMI regarding the incidence of reinfarction and cardiovascular death. However, the long term impact on all-cause death is still unclear. This study corroborates the main findings in the literature, while suggesting lack of effect on overall mortality on a long-term follow-up.

Complete versus culprit-only revascularization in non-ST-segment elevation myocardial infarction and multivessel coronary artery disease

Introduction/Objective. The optimal percutaneous coronary intervention (PCI) in patients with non-STelevated myocardial infarction (NSTEMI) and multivessel coronary artery disease (CAD) is still not clear. The aim of our study was to examine intrahospital and long-term major adverse cardiovascular and cerebrovascular events (MACCE) in this group of patients. Methods. This retrospective study included 225 patients with NSTEMI and multivessel CAD treated with PCI at the Institute of Cardiovascular Diseases of Vojvodina. Three groups were formed: complete one-stage PCI; complete multi-stage PCI, and culprit-only PCI. We analyzed intrahospital and one-year follow-up MACCE and mortality after three years in all three groups. Results. Complete one-stage PCI was performed in 112 (49.8%), complete multi-stage PCI in 70 (31.3%), and culprit-only PCI in 43 (19.1%) patients. Patients with multi-stage complete PCI had the lowest mortality in comparison with one-stage and culprit-only PCI, both intrahospital (0% vs. 0.9% and 20.9%, respectively, p &lt; 0.0005) and after one year (0% vs. 2.7% and 30.2%, respectively, p &lt; 0.0005) and three years (4.3% vs. 5.4% and 32.6%, respectively, p &lt; 0.0005). There was no significant difference in other MACCE between the groups, both intrahospital and after one year. Conclusion. In our study, multi-stage PCI significantly reduces intrahospital, one-year and three-year follow-up mortality in patients with NSTEMI and multivessel CAD.

Meta-Analysis Comparing Fractional Flow Reserve and Angiography-Guided Complete Revascularization of Nonculprit Artery for ST-Elevation Myocardial Infarction

This study aimed to compare complete revascularization (CR) guided by angiography with a fractional flow reserve (FFR)-guided strategy in patients presenting with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD). CR is preferred to culprit-only revascularization for patients with STEMI and MVD. However, whether FFR-guided CR is superior to angiography-guided CR is unclear in patients presenting with STEMI who have MVD. Randomized controlled trials comparing CR with an FFR- or angiography-guided strategy to culprit-only revascularization in patients with STEMI and MVD were systematically identified. A random-effects network meta-analysis was performed comparing clinical outcomes in the 3 arms. A total of 13 studies with a total of 8,927 patients were included in our analysis. Compared with culprit-only revascularization, angiography-guided CR was associated with a significantly decreased risk of myocardial infarction (MI) (hazard ratio [HR] 0.55, 95% confidence interval [CI] 0.37 to 0.82), all-cause death (HR 0.69, 95% CI 0.49 to 0.97), and cardiovascular death (HR 0.54, 95% CI 0.34 to 0.85) but FFR-guided CR was not (MI: HR 0.77, 95% CI 0.53 to 1.12; cardiovascular death: HR 0.89, 95% CI 0.64 to 1.24; all-cause death: HR 0.93, 95% CI 0.72 to 1.18). The network meta-analysis comparison of angiography- versus FFR-guided CR showed an HR of 0.75 (95% CI 0.50 to 1.11) for all-cause death and an HR of 0.71 (95% CI 0.54 to 1.17) for MI. In conclusion, for patients with MVD presenting with STEMI, angiography-guided CR may provide additional benefits compared with FFR-guided CR.