Multivessel Percutaneous Coronary Intervention Research Articles

A-32 | Nationwide Analysis of the Outcomes of Multivessel PCI versus Culprit Vessel-Only PCI in Patients With NSTEMI: A Nationwide Retrospective Observational Study

A-32 | Nationwide Analysis of the Outcomes of Multivessel PCI versus Culprit Vessel-Only PCI in Patients With NSTEMI: A Nationwide Retrospective Observational Study

Benefits of immediate complete revascularization in patients with acute coronary syndromes.

Acute coronary syndrome is one of the leading causes of death worldwide. Up to 60% of patients present with additional significant non-culprit lesions. Complete revascularization (CR) of all (culprit and non-culprit) lesions is recommended and recent randomized trials showed the benefit of performing complete multivessel percutaneous coronary intervention in a single setting. Immediate CR is associated with a reduced risk of repeat myocardial infarction and unplanned ischemia driven revascularization. Furthermore, immediate CR resulted in less implanted stents, total contrast use and a shorter duration of hospitalization while maintaining a similar success rate of complete revascularization. Further studies need to evaluate the role of coronary physiology and intravascular imaging for enhanced understanding of the pathophysiology of early events in non-culprit lesions.

Electrocardiographic patterns and clinical outcomes of acute coronary syndrome cardiogenic shock in patients undergoing percutaneous coronary intervention — A propensity score analysis

ObjectivesTo determine the influence of presenting electrocardiographic (ECG) changes on prognosis in acute coronary syndrome cardiogenic shock (ACS-CS) patients undergoing percutaneous coronary angiography (PCI). BackgroundThe effect of initial ECG changes such as ST-elevation myocardial infarction (STEMI) versus non-STEMI among patients ACS-CS on prognosis remains unclear. MethodsWe analysed data from consecutive patients with ACS-CS enrolled in the Victorian Cardiac Outcomes registry between 2014 and 2020. Inverse probability of treatment weighting analysis (IPTW) was used to assess the effect of ECG changes on 30-day mortality. ResultsOf 1564 patients with ACS-CS who underwent PCI, 161 had non-STEMI and 1403 had STEMI on ECG. The mean age was 66 ± 13 years, and 74 % (1152) were males. Patients with non-STEMI compared to STEMI were older (70 ± 12 vs 65 ± 13 years), had higher rates of diabetes (34 % vs 21 %), prior coronary artery bypass graft surgery (14 % vs 3.3 %), peripheral arterial disease (10.6 % vs 4.1 %, p < 0.01), and lower baseline eGFR (53.8 [37.1, 75.4] vs 65.3 [46.3, 87.8] ml/min/1.73m2), all p ≤ 0.01. Non-STEMI patients were more likely to have a culprit left circumflex artery (29 % vs 20 %) and more often underwent multivessel percutaneous coronary intervention (30 % vs 20 %) but had lower rates of out-of-hospital cardiac arrest (21 % vs 39 %), all p ≤ 0.01. Propensity score analysis with IPTW confirmed that non-STEMI ECG was associated with lower odds for 30-day all-cause mortality (OR 0.47 [0.32, 0.69], p < 0.001), and 30-day major adverse cardiovascular and cerebrovascular events (OR 0.48 [0.33, 0.70]). ConclusionsIn patients undergoing PCI, Non-STEMI as compared to STEMI on index ECG was associated with approximately half the relative risk of both 30-day mortality and 30-day MACCE and could be a useful variable to integrate in ACS-CS risk scores.

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.

Streamlining same-day discharge for percutaneous coronary intervention: A single-center experience

Introduction and objectivesSame-day discharge (SDD) can be considered for patients who traditionally required overnight stay (ONS) after percutaneous coronary intervention (PCI). The authors aimed to evaluate viability of SDD-PCI. MethodsRetrospective single-center observational study of patients who underwent elective PCI. SDD patients were selected based on clinical, angiographic, and sociodemographic characteristics. Patient and procedure characteristics were collected from local databases, and SDD-PCI adverse events (all-cause mortality, acute coronary syndrome, stent thrombosis, reintervention, major bleeding, stroke, contrast-induced renal failure, vascular access complications) at 30-days were analyzed. ResultsThis study included 147 patients, 76% males with a mean age of 66±10, that underwent elective PCI during the first year after implementation of SDD protocol. Most patients undergoing elective PCI were discharged the same day (n=94, 64%). ONS group, when compared to SDD, had higher rates of acute coronary syndrome (38% vs 19%, P=.01) and left ventricular dysfunction (17% vs 6%, P=.04), higher Syntax I score (10 points [6–16] vs 8 points [5–12]; P=.01), more cases of multivessel PCI (24% vs 6%, P<.01) and a surrogate for longer procedures – fluoroscopy time (11min [7–15] vs 8min [5–13]; P=.02). There were no adverse events during the 30-day follow-up period of the patients treated in ambulatory regimen. ConclusionsSDD-PCI is a safe procedure. Protocol implementation is key to guide interventional cardiologists in low-risk patient selection. The potential role in decreasing bed-shortage, hospital overcrowding, and healthcare costs is pivotal.

Zero-contrast Multivessel Percutaneous Coronary Intervention with Intravascular Ultrasound Guidance in a Patient with Acute-on-chronic Kidney Disease: Turn Hopeless into Hopeful

Contrast-induced nephropathy is one of the serious complications in patients with renal dysfunction who underwent administration of intravascular contrast media. To overcome this, an approach of drastic reductions in contrast volume and the use of intravascular ultrasound has been adopted in some clinical cases. This report emphasizes the potential benefits of zero-contrast multivessel percutaneous coronary intervention in a patient presenting with acute-on-chronic kidney disease.

Dual Antiplatelet Therapy De-Escalation in Stabilized Myocardial Infarction With High Ischemic Risk

In patients with acute myocardial infarction (AMI) who have high ischemic risk, data on the efficacy and safety of the de-escalation strategy of switching from ticagrelor to clopidogrel are lacking. To evaluate the outcomes of the de-escalation strategy compared with dual antiplatelet therapy (DAPT) with ticagrelor in stabilized patients with AMI and high ischemic risk following percutaneous coronary intervention (PCI). This was a post hoc analysis of the Ticagrelor vs Clopidogrel in Stabilized Patients With Acute Myocardial Infarction (TALOS-AMI) trial, an open-label, assessor-blinded, multicenter, randomized clinical trial. Patients with AMI who had no event during 1 month of ticagrelor-based DAPT after PCI were included. High ischemic risk was defined as having a history of diabetes or chronic kidney disease, multivessel PCI, at least 3 lesions treated, total stent length greater than 60 mm, at least 3 stents implanted, left main PCI, or bifurcation PCI with at least 2 stents. Data were collected from February 14, 2014, to January 21, 2021, and analyzed from December 1, 2021, to June 30, 2022. Patients were randomly assigned to either de-escalation from ticagrelor to clopidogrel or ticagrelor-based DAPT. Ischemic outcomes (composite of cardiovascular death, myocardial infarction, ischemic stroke, ischemia-driven revascularization, or stent thrombosis) and bleeding outcomes (Bleeding Academic Research Consortium type 2, 3, or 5 bleeding) were evaluated. Of 2697 patients with AMI (mean [SD] age, 60.0 [11.4] years; 454 [16.8%] female), 1371 (50.8%; 684 assigned to de-escalation and 687 assigned to ticagrelor-based DAPT) had high ischemic risk features and a significantly higher risk of ischemic outcomes than those without high ischemic risk (1326 patients [49.2%], including 665 assigned to de-escalation and 661 assigned to ticagrelor-based DAPT) (hazard ratio [HR], 1.74; 95% CI, 1.15-2.63; P = .01). De-escalation to clopidogrel, compared with ticagrelor-based DAPT, showed no significant difference in ischemic risk across the high ischemic risk group (HR, 0.88; 95% CI, 0.54-1.45; P = .62) and the non-high ischemic risk group (HR, 0.65; 95% CI, 0.33-1.28; P = .21), without heterogeneity (P for interaction = .47). The bleeding risk of the de-escalation group was consistent in both the high ischemic risk group (HR, 0.64; 95% CI, 0.37-1.11; P = .11) and the non-high ischemic risk group (HR, 0.42; 95% CI, 0.24-0.75; P = .003), without heterogeneity (P for interaction = .32). In stabilized patients with AMI, the ischemic and bleeding outcomes of an unguided de-escalation strategy with clopidogrel compared with a ticagrelor-based DAPT strategy were consistent without significant interaction, regardless of the presence of high ischemic risk.

German Cardiac Arrest Registry (G-CAR): results of the pilot phase

Abstract Background/Introduction In Europe, over 30.000 persons per year suffer from out-of-hospital cardiac arrest (OHCA). Despite medical progress, survival rates with good neurological outcome remain low. For many important clinical issues, no or only insufficient evidence from randomised trials is available. Therefore, a systemic and standardised acquisition of the treatment course and of the outcome of OHCA patients is warranted. Purpose The German Cardiac Arrest Registry (G-CAR) is an observational, prospective, multicentre registry under the aegis of the German National Cardiac Society. It determines the characteristics, initial treatment strategies, invasive procedures, revascularisation therapies and the use of mechanical circulatory support devices with a focus on extracorporeal cardiopulmonary resuscitation (eCPR). It includes a prospective 12-month follow-up evaluating mortality, neurological outcomes and several patient-reported outcomes in the psychosocial domain, figure 1. Herein, we describe the first results of the pilot phase; more data will be available at the time of the ESC congress. Methods and Results In a pilot phase of 16 months, 15 national centres included 480 consecutive OHCA patients ≥18 years. Median age of the patients was 67 (interquartile range 57;76) years, 74.4% were male. 77.5% of the events were witnessed; bystander CPR was performed in 77.4%. Initial rhythm was shockable in 46.5%. 28.5% of the patients had ongoing CPR at hospital admission. eCPR was performed in 14.1% of the patients. Main presumed underlying causes of CPR were acute coronary syndromes and/or cardiogenic shock in 53.3% followed by primary arrhythmias (7.9%) and hypoxia (5.2%). In 35.2%, ST-segment elevations were observed after return of spontaneous circulation, mostly (62.1%) with an anterior location. In total, 66.6% of the patients underwent coronary angiography. In 71.5%, angiography was performed immediately, in 23.8% within 24 hours and in 4.7% in an elective setting. The LAD was the culprit lesion in 35.8%, the RCA in 17.7%, the LCX in 10.6% and the LM in 5.1%. In 30.3%, there was either no or an unclear culprit lesion. Regarding the strategy of percutaneous coronary intervention (PCI), culprit-only PCI was performed in 74.5%, multivessel PCI in 25.5%. Targeted temperature management was performed in 79.8%, with an invasive approach and non-invasive approach in approximately 50% each. In-hospital mortality was 69.2%, with anoxic brain damage being the main presumed cause of death (37.3%) followed by circulatory failure in 26.2%. Conclusions G-CAR is a multicenter German registry for adult OHCA patients including long-term follow-up. Primary aim is a better understanding of the determinants of acute and long-term outcomes with the perspective of an optimised treatment. Parallel to further in-depth analyses of the pilot phase including patient-reported outcomes, scaling up of G-CAR to a national level is envisaged.Registry flow-chartFirst results pilot phase G-CAR

New criteria to identify patients at higher risk for cardiovascular complications after percutaneous coronary intervention

Abstract A universal definition to identify patients at higher risk of complications after percutaneous coronary intervention (PCI) is lacking. We aimed to validate a recently developed score to identify patients at increased risk of all-cause death after PCI. All consecutive patients from a large PCI registry not presenting with ST-elevation myocardial infarction or cardiogenic shock were included. Each patient was assigned a score obtained by summing the points associated with the following variables: age &amp;gt;80 years (3 points), dialysis (6 points), left ventricular ejection fraction &amp;lt;30% (2 points), and multivessel PCI (2 points). Patients were stratified in 3 groups: low risk (score 0), intermediate risk (score 2 to 3), or high risk (score ≥4). The primary outcome was all-cause death, and the secondary outcomes were major adverse cardiovascular events and major bleeding. Events were assessed at 1 year after PCI. Between January 2014 and December 2019, 12,689 patients underwent PCI. Compared with the 9,884 patients at low risk, those at intermediate and high risk had a fourfold (hazard ratio 3.99, 95% confidence interval 2.95 to 5.38) and ninefold (hazard ratio 9.55, 95% confidence interval 6.89 to 13.2) higher hazard for all-cause death at 1 year, respectively. The score had a good predictive value for all-cause death at 1 year (area under the curve 0.70). The risk of major adverse cardiovascular events and major bleeding increased consistently from the low- to the high-risk group. In conclusion, in patients who underwent PCI for stable ischemic heart disease or non−ST-elevation acute coronary syndrome, a score based on 4 variables well predicted the risk of all-cause death at 1 year.Derivation of risk scoreAll-cause death rate at 1 year

Patient-level outcomes of patients undergoing resorbable magnesium scaffold (RMS) implantation stratified according to different subgroups: a post-hoc analysis of SHERPA MAGIC study

Abstract Background The SHERPA-MAGIC is an investigator-driven, multicenter, prospective, single-arm study that enrolled patients undergoing resorbable magnesium scaffold (RMS) implantation in 18 Italian centers. The results from the first 543 patients supported the safety and long-term performance of RMS in a real-world population. Purpose The present post-hoc analysis aimed to assess differences in adverse events at patient-level (patient-oriented composite endpoints, POCE, defined as the composite of all-cause death, myocardial infarction -MI- and ischemia-driven coronary revascularization) at the longest follow-up between different subgroups of the final study population (n=543). Methods We identified the subgroups according to different variables: age, sex, cardiovascular risk factors, clinical presentation, left ventricle ejection fraction, multivessel disease, multivessel PCI, and antiplatelet therapy. If the analysis highlighted a subgroup of patients at higher risk of adverse events, to understand if this finding is related to RMS implantation or to the characteristic itself, a propensity score matched analysis was conducted comparing patients of the SHERPA-MAGIC study with a matched cohort of patients receiving second generation drug eluting stent. The endpoint for the comparison between the two matched cohorts was POCE. Results The mean age of the final study population was 56±9 years. 433 (78%) patients were men, and the most common clinical presentation was MI (n=402, 74%). At the median follow-up of 3.5 [2.6-4.3] years, the cumulative occurrence of the primary endpoint (vessel-oriented composite endpoints, VOCE, including cardiac death, target vessel MI, and ischemia-driven target vessel revascularization) was 37 (5.8%, 95%CI 4.1%-7.9%) and 54 (9.9%, 95% CI 7.5%-12.7%) patients met criteria for POCE. There was no significant difference among POCE in the subgroup analysis (Figure 1), with the exception of patients with MI as clinical presentation. As compared to patients admitted for chronic coronary syndrome, MI patients showed a significantly higher POCE rate (11.4 vs 5.6%, CI 8.5-14.9, p=0.04). Therefore, a propensity score matched analysis was conducted comparing MI patients of the SHERPA-MAGIC study with a matched cohort of MI patients from the Acute coRonary sYndrOmes proSpective regisTry Of Ferrara (ARYOSTO) study (NCT02438085) treated with second-generation DES. We did not find significant differences in the cumulative occurrence of POCE between SHERPA MAGIC and ARYOSTO (11.4% vs. 12.5% respectively, p=0.71) (Figure 2). Conclusions The present analysis confirmed the safety and effectiveness of RMS across several subgroups of patients stratified by clinical and procedural characteristics. We found that MI patients had an higher occurrence of POCE, but this was not related to RMS implantation. Indeed, a similar MI population treated with second generation DES showed the same long-term outcome.Fig 1POCE difference between subgroupsFig 2Propensity matched MI populations

Intracoronary imaging guided percutaneous coronary intervention of stent restenosis: does it make a difference?

Abstract Background In-stent restenosis (ISR) remains the most common cause of stent failure after percutaneous coronary intervention (PCI). Compared to coronary angiography (CA), intracoronary imaging (ICI) provides a more accurate and detailed characterization of the degree of ISR and may help identify the underlying pathophysiological mechanism. Although recommended in the European guidelines, the impact of ICI in clinical outcomes in ISR is still under discussion. Purpose Our study aimed to analyze and compare clinical outcomes between CA PCI (group 1 - G1) and ICI-guided PCI (Intravascular ultrasound (IVUS) or optical coherence tomography (OCT)) (group 2 - G2). Methods We performed a retrospective single-center review of all consecutive patients with ISR treated in our center from September 2014 to January 2022. Patients with acute stent thrombosis were excluded. Primary endpoint was defined as death by all causes and secondary endpoint as a composite of cardiovascular (CV) mortality, culprit ISR PCI and ischemic stroke. Results 130 patients were included (mean age 66.23 ± 11.832 years, 77.7% male and mean follow-up period (FUP) 48.70 ± 27.356 months). Mean left ventricular ejection fraction was 50.19 ± 10.509%, 66.2% had dyslipidemia, 45.3% hypertension, 38.5% diabetes, 36.2% heart failure and 29.2% previous multivessel PCI. A total of 142 ISR lesions from 136 arteries were treated and ICI was used in 37 (28.5%) patients (IVUS in 16 (12.3%) and OCT in 21 (16.2%)). The ISR coronary segment and pattern is described in Table 1. The mechanism for ISR was identified in 23 lesions. The most common indication for coronary angiography was stable angina in 34.6% and NSTEMI in 31.5% and ISR was the culprit in 128 (98.5%) of the cases. The groups were well matched regarding baseline characteristics and comorbidities. PCI strategy was more often drug-eluting stenting (DES) vs drug-coated balloon (DCB) in group 2 (DES 18.3% vs 51.4% and DCB 81.7% vs 43.2% in G1 and G2 respectively). And, as expected, treatment of bifurcation lesions was more frequent in group 2 (9.7% G1 vs 30.6% G2). During the FUP there were 10 (7.7%) CV deaths and 19 (14.6%) non-CV deaths (19 in G1 and 0 in G2). The composite outcome of CV mortality, ischemic stroke and culprit ISR PCI occurred in 19 (20.2%) patients in G1 and 1 (2.7%) patient in G2. The use of ICI was associated with reduced all-cause mortality (HR=0.667 [95% CI 0.584-0.760], p=0.011) and reduced composite outcome (B (95%CI): -0.251 (-0.455 - -0.046), p=0.017). No difference between IVUS or OCT was found. The PCI strategy (DES vs DCB), stent type, length or diameter were not predictors of outcomes. Conclusion In IRS PCI, the use of ICI compared to standard of care CA was associated with a reduction in all-cause mortality and composite outcome of CV mortality, culprit ISR PCI and ischemic stroke. The strategy of PCI differed with DES being used more frequently than DCB. No difference between IVUS or OCT was found.

Interim prediction of two-year all-cause mortality in patients with de novo multivessel coronary artery disease undergoing intended multivessel PCI

Abstract Background/Introduction coronary revascularization in patients with de novo three-vessel coronary artery disease (3VD) without Left Main disease can be performed by either PCI or CABG after objective Heart Team consensus. In the ongoing Multivessel TALENT trial (NCT04390672)1, the intended multivessel PCI is performed using DES with ultrathin struts and biodegradable polymers under the guidance of quantitative flow ratio (QFR) and intracoronary imaging with IVUS or OCT. Purpose The Logistic Clinical SYNTAX score (logSYNTAX) to predict 2-year all-cause mortality after PCI was developed in 15,883 patients treated in the GLOBAL LEADERS trial and externally validated in 10,100 patients. This study aims to predict 2-year all-cause mortality after intended multivessel PCI in the currently enrolled trial population to identify patients who should be considered high risk. Methods and results We performed an interim analysis in the first consecutive 781 patients of the ongoing Multivessel TALENT Trial aimed to enrol 1550 patients. Thirteen clinical predictors are used in the logSYNTAX score: SYNTAX I-score, presence of 3VD and/or LM disease, age, creatinine clearance in mL/min, LVEF, BMI, serum hemoglobin level(g/dL), the White Blood Cell Count (WBC, in 109 cells/L) and the presence of COPD, PVD, diabetes mellitus, current smoking and/or a history of stroke. LVEF and BMI have additional squared terms to adjust for non-linear associations with all-cause mortality. The predicted mortality was estimated using the survival function developed in the GLOBAL LEADERS trial. We considered patients high-risk if the estimated risk was above the 3rd quartile. In 563 patients, all thirteen predictors necessary for 2-year mortality prediction were available. Median 2-year all-cause mortality of 1.9% (1.09-3.82; IQR2.73). 142 patients (25%) with an increased estimated 2-year mortality risk (&amp;gt;3.8%) due to higher prevalence of the aforementioned predictors; higher median age [75 (9.0) vs. 67 (12.0), p &amp;lt;0.001], a lower median LVEF [55% (20) vs. 94% (35.5), p &amp;lt;0.001] and a higher median SYNTAX score [26.0 (13.5) vs. 20.0(11.0), p &amp;lt;0.001]. A complete overview of predictors can be found in table 1. High age, an impaired LVEF, and an increased anatomical SYNTAX-I score were the main contributors to high mortality in this study cohort (see figure 1). Conclusion(s) In 563 patients, the median predicted 2-year all-cause mortality was 1.9%. Nevertheless, a non-neglectable amount of patients were estimated to be at increased risk for all-cause 2-year mortality. Accurate prediction by knowledge of aforementioned predictors is pivotal for appropriate mortality risk prediction to segregate high-risk patients with 3VD for individual decision-making on coronary revascularization, even if surgical revascularization is no option, and guide optimal treatment with use of intravascular imaging to achieve an optimal PCI result.Table 1Figure 1

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 15339: CAD Polygenic Risk Score and Incident Complex Coronary Revascularization in Adults With Atherosclerosis

Introduction: A CAD polygenic risk score (CAD PRS) was previously shown to predict major vascular events among patients with established ASCVD. Whether genetic risk can predict the need for complex coronary revascularization procedures, including complex PCI or CABG, has not been established. Methods: The FOURIER trial randomized 27,564 patients with established ASCVD to evolocumab or placebo with a median follow-up of 2.2 years. Of these, 14,298 had genotype data and were used in this analysis. The CAD PRS was previously derived in a CAD GWAS and includes 2,293,205 SNPs. Clinical records were reviewed for coronary revascularization events to determine procedural characteristics and coronary anatomy. Complex revascularization was defined as complex PCI [multivessel PCI, &gt;3 lesions, &gt;3 stents, total stent length &gt;60mm, or bifurcation PCI] or CABG. Associations between the CAD PRS and revascularization events were analyzed by PRS quintile. Results: Patients with higher CAD PRS were significantly more likely to undergo complex coronary revascularization than those with low genetic risk (Q5 vs Q1: HR 1.71; 95% CI 1.23-2.37; P=0.002) (Fig A), with a greater than 2-fold higher risk of complex PCI (HR 2.11; 1.33-3.35) and a numerically higher risk of CABG (HR 1.28; 0.80-2.05). These findings were directionally consistent for the individual components of complex PCI, including multivessel PCI (HR 1.71; 0.97-3.00), &gt; 3 lesions (HR 1.85; 0.73-4.68), &gt; 3 stents (HR 3.77; 1.75-8.12), stent length &gt;60 mm (HR 2.07; 0.88-4.87), and bifurcation PCI (HR 2.17; 0.39-11.98) (Fig B). Conclusions: Among patients with established ASCVD, a CAD PRS predicted incident complex coronary revascularization procedures. Genetic prediction of advanced coronary disease requiring specific complex interventions has not previously been shown, and these findings may have the potential to yield novel approaches for reducing the need for these high-risk and costly procedures.

Revascularization strategies for multivessel coronary artery disease based on sex and age.

This study describes coronary revascularization strategies used by sex and age in the USA. A sex-stratified cohort study from the National Inpatient Sample from the Agency for Healthcare Research and Quality (USA) including patients admitted for coronary revascularization with primary or secondary diagnoses of chronic coronary syndrome or non-ST elevation myocardial infarction who underwent ≥3-vessel coronary artery bypass grafting or percutaneous coronary intervention from January 2019 to December 2020. The primary outcome was the use rate of coronary artery bypass grafting or multivessel percutaneous coronary intervention. Prespecified subgroups included age and non-ST elevation myocardial infarction. Among 121150 patients (21.7% women), there were no sex differences in age (women: 66.6 [66.5-66.7], men: 67.6 [67.5-67.7], standardized mean difference: 0.1) or non-ST elevation myocardial infarction incidence (women: 37.4%, men: 45.7%, standardized mean difference: 0.17). The majority of women (74.2%) and men (84.9%) underwent bypass grafting, which was unaffected by age, race or non-ST elevation myocardial infarction. Women were less likely to undergo bypass grafting than percutaneous intervention (adjusted odds ratio 0.49, 95% confidence interval 0.44-0.54; P < 0.001) and a disparity most pronounced in patients >80 years old (adjusted odds ratio 0.31, 95% confidence interval 0.22-0.45; P < 0.001). Most patients with multivessel coronary artery disease needing revascularization undergo bypass grafting, irrespective of sex, age or clinical presentation. The sex disparity in the use of bypass grafting is mostly seen among patients >80 years old.

Dual Antiplatelet Therapy Duration After Multivessel Optimal Intravascular Ultrasound-Guided Percutaneous Coronary Intervention.

There is a scarcity of data evaluating contemporary real-world dual antiplatelet therapy (DAPT) strategies after percutaneous coronary intervention (PCI).Methods and Results: In the OPTIVUS-Complex PCI study multivessel cohort enrolling 982 patients undergoing multivessel PCI, including left anterior descending coronary artery using intravascular ultrasound (IVUS), we conducted 90-day landmark analyses to compare shorter and longer DAPT. DAPT discontinuation was defined as withdrawal of P2Y12inhibitors or aspirin for at least 2 months. The prevalence of acute coronary syndrome and high bleeding risk by the Bleeding Academic Research Consortium were 14.2% and 52.5%, respectively. The cumulative incidence of DAPT discontinuation was 22.6% at 90 days, and 68.8% at 1 year. In the 90-day landmark analyses, there were no differences in the incidences of a composite of death, myocardial infarction, stroke, or any coronary revascularization (5.9% vs. 9.2%, log-rank P=0.12; adjusted hazard ratio, 0.59; 95% confidence interval, 0.32-1.08; P=0.09) and BARC type 3 or 5 bleeding (1.4% vs. 1.9%, log-rank P=0.62) between the off- and on-DAPT groups at 90 days. The adoption of short DAPT duration was still low in this trial conducted after the release of the STOPDAPT-2 trial results. The 1-year incidence of cardiovascular events was not different between the shorter and longer DAPT groups, suggesting no apparent benefit of prolonged DAPT in reducing cardiovascular events even in patients who undergo multivessel PCI.

Guiding Intervention for Complex Coronary Lesions by Optical Coherence Tomography or Intravascular Ultrasound

BackgroundOptical coherence tomography (OCT) and intravascular ultrasound (IVUS) have shown comparable outcomes in guiding percutaneous coronary intervention (PCI). However, their comparative effectiveness in complex coronary artery lesions remains unclear. ObjectivesThis study compared the effectiveness and safety of OCT-guided vs IVUS-guided PCI for complex coronary artery lesions. MethodsThis was a prespecified, main subgroup analysis of complex coronary artery lesions in the OCTIVUS (Optical Coherence Tomography Versus Intravascular Ultrasound Guided Percutaneous Coronary Intervention) trial, which included unprotected left main disease, bifurcation disease, an aorto-ostial lesion, a chronic total occlusion, a severely calcified lesion, an in-stent restenotic lesion, a diffuse long lesion, or multivessel PCI. The primary endpoint was a composite of death from cardiac causes, target vessel–related myocardial infarction, or ischemia-driven target vessel revascularization. ResultsIn 2,008 randomized patients, 1,475 (73.5%) underwent imaging-guided PCI for complex coronary artery lesions; 719 (48.7%) received OCT-guided and 756 (51.3%) IVUS-guided PCI. At a median follow-up of 2.0 years, primary endpoint event had occurred in 47 patients (6.5%) in the OCT-guided group and in 56 patients (7.4%) in the IVUS-guided group (HR: 0.87; 95% CI: 0.59-1.29; P = 0.50). These findings were consistent in adjusted analyses. The incidence of contrast-induced nephropathy was similar between the 2 groups (1.9% vs 1.5%; P = 0.46). The incidence of major procedural complications was lower in the OCT-guided group than in the IVUS-guided group (1.7% vs 3.4%; P = 0.03). ConclusionsAmong patients with complex coronary artery lesions, OCT-guided PCI showed a similar risk of primary composite event of death from cardiac causes, target vessel–related myocardial infarction, or target vessel revascularization as compared with IVUS-guided PCI. (Optical Coherence Tomography Versus Intravascular Ultrasound Guided Percutaneous Coronary Intervention [OCTIVUS]; NCT03394079)

Meta-analysis of immediate complete vs staged complete revascularization in patients with acute coronary syndrome and multivessel disease

BackgroundRandomized controlled trials (RCTs) have shown varying results between immediate and staged complete percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) and multivessel disease (MVD). We conducted a meta-analysis to reconcile the findings. MethodsOnline databases were searched for RCTs comparing immediate vs staged complete PCI in patients presenting with ACS. The outcomes of interest were major adverse cardiovascular events (MACE), all cause death, myocardial infarction (MI), cardiovascular death, stent thrombosis, target vessel revascularization (TVR), cerebrovascular events, bleeding and acute kidney injury (AKI)/contrast induced nephropathy (CIN). Risk ratios (RR) with 95 % confidence intervals (CI) were calculated using the random-effects model. ResultsNine RCTs with a total of 3637 patients - 1821 in the immediate PCI group and 1816 in the staged PCI group, were included. The mean age was 64 years, 78 % of patients were men and the mean duration of follow up was 1 year. As compared with staged complete PCI, the immediate PCI group was associated with significant reduction of MI (RR 0.53, 95 % CI 0.36–0.77) and TVR (RR 0.69, 95 % CI 0.53–0.90). The risks of all-cause death, cardiovascular death, MACE, cerebrovascular events, stent thrombosis, bleeding and AKI/CIN were similar in the two groups. ConclusionsIn ACS patients selected for complete revascularization strategy, multivessel PCI during the index procedure may be associated with significant reduction in the risk of MI and TVR without harm when compared with a staged PCI strategy.

SYNTAX Score and 1-Year Outcomes in the OPTIVUS-Complex PCI Study Multivessel Cohort

The optimal revascularization strategy in patients with multivessel disease and intermediate SYNTAX score (SS) has not been fully elucidated. This study aimed to investigate the clinical outcomes of optimal intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) stratified by SS. This was a substudy of the OPTIVUS-Complex PCI study Multivessel Cohort, which aimed to meet the prespecified criteria for optimal stent expansion after IVUS-guided PCI. A total of 1,005 patients were divided into 3 groups according to SS: low, ≤22; intermediate, 23 to 32; and high, ≥33. The primary end points were major adverse cardiac and cerebrovascular events (MACCE) defined as a composite of death, myocardial infarction, stroke, or coronary revascularization. The cumulative 1-year incidence of the primary end point was significantly higher in patients with high SS than in those with intermediate or low SS (25.0%, 10.9%, and 9.5%, respectively; p=0.003). This difference was mainly caused by the incidence of coronary revascularization. In the multivariable Cox proportional hazards models, the excess risk of patients with high versus low SS remained significant for the primary end point (hazard ratio 3.19, 95% confidence interval 1.65 to 6.16, p <0.001), whereas the excess risk of patients with intermediate versus low SS was no longer significant (hazard ratio 1.20, 95% confidence interval 0.72 to 2.01, p=0.46). After IVUS-guided multivessel PCI, patients with intermediate SS had a similar 1-year risk of MACCE to that of patients with low SS, whereas patients with high SS had a higher 1-year risk of MACCE than those with low SS.

Timing of Complete Revascularization with Multivessel PCI for Myocardial Infarction

BackgroundIn patients with ST-segment elevation myocardial infarction (STEMI) with multivessel coronary artery disease, the time at which complete revascularization of nonculprit lesions should be performed remains unknown.MethodsWe performed an international, open-label, randomized, noninferiority trial at 37 sites in Europe. Patients in a hemodynamically stable condition who had STEMI and multivessel coronary artery disease were randomly assigned to undergo immediate multivessel percutaneous coronary intervention (PCI; immediate group) or PCI of the culprit lesion followed by staged multivessel PCI of nonculprit lesions within 19 to 45 days after the index procedure (staged group). The primary end point was a composite of death from any cause, nonfatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure at 1 year after randomization. The percentages of patients with a primary or secondary end-point event are provided as Kaplan–Meier estimates at 6 months and at 1 year.ResultsWe assigned 418 patients to undergo immediate multivessel PCI and 422 to undergo staged multivessel PCI. A primary end-point event occurred in 35 patients (8.5%) in the immediate group as compared with 68 patients (16.3%) in the staged group (risk ratio, 0.52; 95% confidence interval, 0.38 to 0.72; P<0.001 for noninferiority and P<0.001 for superiority). Nonfatal myocardial infarction and unplanned ischemia-driven revascularization occurred in 8 patients (2.0%) and 17 patients (4.1%), respectively, in the immediate group and in 22 patients (5.3%) and 39 patients (9.3%), respectively, in the staged group. The risk of death from any cause, the risk of stroke, and the risk of hospitalization for heart failure appeared to be similar in the two groups. A total of 104 patients in the immediate group and 145 patients in the staged group had a serious adverse event.ConclusionsAmong patients in hemodynamically stable condition with STEMI and multivessel coronary artery disease, immediate multivessel PCI was noninferior to staged multivessel PCI with respect to the risk of death from any cause, nonfatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure at 1 year. (Supported by Boston Scientific; MULTISTARS AMI ClinicalTrials.gov number, NCT03135275.)