Non-infarct Related Artery Research Articles

The CULPRIT SHOCK trial: a favourable verdict for the only-culprit percutaneous coronary intervention strategy

Falsifiability is the heart of science, and I could add, falsifiability affects also the science of the heart. In August 2017 the back then new released guidelines of the European Society of Cardiology for management of ST elevated myocardial infarction (STEMI) included as a recommendation class IIa (level C) the percutaneous coronary intervention (PCI) of non-infarct related artery during the index procedure in patients with STEMI, multivessel disease (MVD) presenting with cardiogenic shock (CS) (1). Just few weeks later, this statement was seriously challenged by the CULPRIT-SHOCK trial (2), and one year later, the new European guidelines for myocardial revascularization downgraded the aforementioned recommendation to class III (3).

Abstract 17197: Preventive Multivessel Percutaneous Coronary Intervention in St Segment Myocardial Infarction is Associated With Worse Outcomes Than Infarct Related Artery Intervention Alone - A Propensity Matched Comparison

Introduction: Recent trials have suggested potential benefits of performing multivessel percutaneous coronary intervention (MVPCI) on non-infarct related artery (non-IRA) in ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease. Methods: National Readmissions Database (NRD) 2010-14 was utilized to select study cohort. Appropriate International Classification of Diseases, 9th Revision (ICD-9-CM) diagnostic and procedural codes were utilized to identify STEMI patients undergoing multivessel PCI and infarct-related artery only PCI (IRA-PCI). Propensity score matched cohorts using greedy matching algorithm were generated for comparison of outcomes. Results: We identified 116592 IRA-PCI (83.97%) and 22257 MVPCI (16.03%) cases. With 1:3 propensity matched cohorts accounting for confounders such as age, gender, race and comorbidities, in comparison to IRA-PCI, MVPCI patients have higher 30-day readmission rate (10.40% vs 9.40%, p=0.001), in-hospital mortality (1.96% vs 1.57%,p<0.001), mechanical circulatory support utilization (4.27 vs 2.44%,p<0.001) as well as higher complication including vascular (0.51% vs 0.28%, p<0.001), cardiac (5.97% vs 3.97%, p<0.001), respiratory (4.89% vs 4.02%,p<0.001), neurologic complications (0.77% vs 0.58%,p=0.003), major bleeding (1.01% vs 0.79%, p=0.002) and cardiac arrest(3.48% vs 3.17%, p=0.027). We also noted higher cost of care ($27100 vs $20900, p<0.001) and length of stay (3.8 days vs 3.4 days, p<0.001) in MVPCI group compared to IRA-PCI group. Conclusions: We noted higher 30- day readmission rate, in-hospital mortality, complications and resource utilization with MVPCI compared to IRA-PCI approach among STEMI patients which further demands large-scale randomized control trials to determine the utility of MVPCI in the “real world”.

Trends in the history and fate of patients hospitalized for acute myocardial infarction

The aim of the study is to report on the history of ischemic heart disease (IHD), clinical course and early and late mortality in 1291 middle-aged men (<65 years) hospitalized for acute myocardial infarction in the 2006a2016 period. All patients admitted within 24h (90% of patients) underwent angiography on arrival; urgent infarct-related artery PCI was performed in 85.4% of all patients; of these 14.6% had PCI on another (non-infarct related) artery PCI while 7.7% had coronary artery bypass grafting (CABG). Primary ventricular fibrillation and cardiogenic shock occurred in 8.6% and 5.1% of patients, respectively. Cardiogenic shock-related mortality was 53%. Twenty-eight-day mortality in our entire patient cohort was 4.8%, with one-year mortality (28 days onward to 1 year) being 1.7%. Long-term mortality of our cohort, monitored until end of 2015, was adversely affected by older age, pre-existing coronary heart disease [finding based on data above previous PCI or CABG, or previous myocardial infarction (p<0.040)], low left ventricular ejection fraction on admission (p<0.001; <35%) and manifestations of acute heart failure (shock; Killip III; p<0.001). A total of 1158 patients lived longer than one year, of which number 79.3% were available for outpatient assessment at 1 year. Another non-fatal event occurred in only 8 patients (0.9%), with angina reported by 54 men (5.9%).Another aim of our study was to document changes in the history of IHD, clinical picture and death rates occurring in men in the above age category between 1970 and 2016. Analysis and comparison of these parameters were made using the World Health Organization (WHO) and European Society of Cardiology (ESC) registries as well as of our own datasets obtained between 1970 and 1977, in the 1991a1995 period (thrombolytic era) and the most recent dataset collected between 2006 and 2016. In-hospital (28-day) mortality decreased from 15 to 16.6% in the pre-reperfusion therapy period through 8.7% in the thrombolytic era down to the most recent 4.8% reported in the 2006a2016 period. This was paralleled by a decrease in one-year mortality (28+ to 365 days) declining as it did from 11.5% to the current 1.6%. Marked changes were likewise seen in the past history of patients. The incidence of pre-existing angina decreased from 42% in the 1970s to 24% in the predominantly thrombolytic era down to the current 6.1%. A similar downward trend was noted in the incidence of previous myocardial infarction, falling from 25 to 30% to the current 9.6%.The lower incidence of angina prior to the event as well as previous myocardial infarction can be attributed not only to more effective medication and secondary prevention but, also, to the current strategies of revascularization in patients with angina and early myocardial revascularization in individuals experiencing a coronary event.Taken together, the factors behind the reduced mortality of patients hospitalized for acute myocardial infarction are not only early infarct-related artery recanalization but, also, a lower incidence of a previous myocardial infarction plus better status of the coronary vascular bed in patients with previously diagnosed angina and previous myocardial infarction.

Microvascular obstruction in non-infarct related coronary arteries is an independent predictor of major adverse cardiovascular events in patients with ST segment-elevation myocardial infarction

BackgroundCoronary microvascular obstruction (MVO) in infarct-related artery (IRA) territory has been associated with worse cardiovascular outcomes in patients presenting with ST-segment elevation myocardial infarction. However, the prognostic value of non-IRA MVO in this patient population remains unknown. Methods and resultsOne hundred ninety nine patients presenting to our institution with STEMI were enrolled. All patients underwent primary percutaneous coronary intervention per institutional STEMI protocol followed by a cardiac MRI within 1 week of presentation and the IRA and non-IRA MVO segments were determined. All cause death, recurrent myocardial infarction, hospitalization for heart failure, and ventricular tachycardia were counted as major adverse cardiovascular events (MACE). Patients with non-IRA MVO had lower composite MACE free survival at 6 months (HR 2.15, 95% CI, 1.06–4.35; p = 0.029) compared to those without non-IRA MVO. In a sub-analysis of patients with multi vessel disease (MVD), patients with non-IRA MVO also had lower composite MACE-free survival at 6 months as compared to those without non-IRA MVO (HR 2.47, 95% CI, 1.02–5.97; p = 0.037). Non-IRA MVO continued to be predictive of MACE in a cox proportional hazards model adjusting for additional prognostic factors using inverse probability weighting (p = 0.007). Non-IRA MVO was more prevalent in patients with LAD culprit vessel STEMI rather than those with RCA or Circumflex culprit vessels (p < 0.001). ConclusionsPatients presenting with STEMI and non-IRA MVO have significantly lower MACE free survival at 6 months as compared to those without non-IRA MVO.

Appropriate use of noninvasive ischemia testing to guide revascularization decision making following acute ST elevation myocardial infarction in Latin American countries: Results from an Expert Panel Meeting of the International Atomic Energy Agency

Across Latin American and Caribbean countries (LAC), cardiovascular disease and especially ischemic heart disease is currently the main cause of death both in men and in women. For most LAC, public and community health efforts aim to define care strategies which are both clinically and cost effective and promote primary and secondary prevention, resulting in improved patient outcomes. The optimal approach to deal with acute events such as ST-elevation myocardial infarction (STEMI) is a matter of controversy; however, there is an expanding role for assessing residual ischemic burden in STEMI patients following primary percutaneous coronary intervention (PPCI). Although randomized clinical trials have established the value of staged fractional flow reserve (FFR)-guided revascularization, the use of noninvasive functional imaging modalities may play a similar role at a much lower cost. For LAC, available stress imaging techniques could be applied to define residual ischemia in the non-infarct related artery and to target revascularization in a staged procedure after PPCI. The use of nuclear cardiac imaging, supported by its relatively wide availability, moderate cost, and robust quantitative capabilities, may serve to guide effective care and to reduce subsequent cardiac events in patients with coronary artery disease. This noninvasive approach may avert potential safety issues with repeat and lengthy invasive procedures, and serve as a baseline for subsequent follow-up stress testing following the index STEMI event. This consensus document was devised from an Expert Panel Meeting of the International Atomic Energy Agency (IAEA), highlighting available evidence with a focus on the utility of stress myocardial perfusion imaging in post-STEMI patients. The document could serve as guidance to the prudent and appropriate use of nuclear imaging for targeting therapeutic management and avoiding unnecessary invasive procedures within LAC, where resources could be scarce.

Multivessel Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction With Cardiogenic Shock

BackgroundRecent trials demonstrated a benefit of multivessel percutaneous coronary intervention (PCI) for noninfarct-related artery (non-IRA) stenosis over IRA-only PCI in patients with ST-segment elevation myocardial infarction (STEMI) multivessel disease. However, evidence is limited in patients with cardiogenic shock. ObjectivesThis study investigated the prognostic impact of multivessel PCI in patients with STEMI multivessel disease presenting with cardiogenic shock, using the nationwide, multicenter, prospective KAMIR-NIH (Korea Acute Myocardial Infarction-National Institutes of Health) registry. MethodsAmong 13,104 consecutive patients enrolled in the KAMIR-NIH registry, we selected patients with STEMI with multivessel disease presenting with cardiogenic shock and who underwent primary PCI. Primary outcome was 1-year all-cause death, and secondary outcomes included patient-oriented composite outcome (a composite of all-cause death, any myocardial infarction, and any repeat revascularization) and its individual components. ResultsA total of 659 patients were treated by multivessel PCI (n = 260) or IRA-only PCI (n = 399) strategy. The risk of all-cause death and non-IRA repeat revascularization was significantly lower in the multivessel PCI group than in the IRA-only PCI group (21.3% vs. 31.7%; hazard ratio: 0.59; 95% confidence interval: 0.43 to 0.82; p = 0.001; and 6.7% vs. 8.2%; hazard ratio: 0.39; 95% confidence interval: 0.17 to 0.90; p = 0.028, respectively). Results were consistent after multivariable regression, propensity-score matching, and inverse probability weighting to adjust for baseline differences. In a multivariable model, multivessel PCI was independently associated with reduced risk of 1-year all-cause death and patient-oriented composite outcome. ConclusionsOf patients with STEMI and multivessel disease with cardiogenic shock, multivessel PCI was associated with a significantly lower risk of all-cause death and non-IRA repeat revascularization. Our data suggest that multivessel PCI for complete revascularization is a reasonable strategy to improve outcomes in patients with STEMI with cardiogenic shock.

Short-term coronary physiology parameters evolution in acute coronary syndrome patients with multivessel disease treated with ticagrelor

Ticagrelor increases adenosine plasma concentration in acute coronary syndrome patients (ACS) by inhibiting adenosine uptake by red blood cells. Besides, ticagrelor treatment might be more effective than clopidogrel in reducing microvascular injury in ST-elevation myocardial infarction (STEMI) patients. However, the effects of ticagrelor on coronary physiology parameters in ACS patients with multivessel disease (MVD) remain uncertain. We designed a prospective study to assess the effects of ticagrelor treatment on microvascular resistance in ASC patients with MVD. Ten consecutive non-STE-ASC patients with no prior ticagrelor treatment and MVD, defined as the presence of at least one significant (> 50%) lesion in a non-infarct related artery, underwent intracoronary physiology parameters assessment immediately after primary percutaneous coronary intervention (PCI) of the culprit lesion. A second series of measurements was performed after 72 hours of ticagrelor treatment. The primary endpoint was the index of microvascular resistance (IMR) in a non-infarct related artery. The secondary endpoints were IMR in the culprit artery and the fractional flow reserve (FFR) both in a non-infarct related artery and in the culprit artery. IMR measured in a non-infarct related artery was significantly lower after 72 h of ticagrelor treatment (19.2 ± 11.2 vs. 14.2 ± 7.4, P = 0.02) whereas IMR in the culprit artery was not significantly different from baseline (13.1 ± 4.1 vs. 18.7 ± 11.4, P = 0.13). FFR measurements were not significantly different after ticagrelor treatment both in the non-infarct related artery and in the culprit artery after primary PCI (85 ± 0.15 vs. 0.86 ± 0.17, P = 0.80 and 0.98 ± 0.04 vs. 0.98 ± 0.04, P = 0.56 respectively) ( Table 1 ). Ticagrelor decreases microvascular resistance in non-infarct related artery in ASC patients with MVD.

Successful revascularization of noninfarct related artery with chronic total occlusion among acute myocardial infarction patients: A systematic review and meta-analysis.

Background:Randomized trials and meta-analyses demonstrated that chronic total occlusion (CTO) in noninfarct related artery (n-IRA) was associated with increased all-cause mortality. Recently, several observational studies suggested that the successful revascularization of n-IRA with CTO decreased all-cause mortality.Methods:A systematic search was performed in Cochrane Controlled Trials Registry, PubMed, MEDLINE, and EMBASE databases for relevant studies. Article assessing the prognostic role of revascularization of n-IRA with CTO was enrolled in this meta-analysis. Data and characteristics of each study were extracted. A meta-analysis was performed to generate pooled odds ratio (OR) and 95% confidence intervals (95% CIs) for outcomes. The primary outcome was major adverse cardiac events (MACE). Beg funnel plot was used to evaluate publication bias.Results:Four observational studies and one randomized controlled trial involving 1083 patients were enrolled for analysis. Compared with nonreperfusion, the successful percutaneous coronary intervention (PCI) of n-IRA with CTO was related to decreased all-cause mortality (OR was 0.34, and 95% CI was 0.2–0.59; P = .0001).Conclusions:Successful PCI of n-IRA with CTO could significantly decrease all-cause mortality, cardiac mortality, MACE, and stroke in acute myocardial infarction patients. In addition, it was not associated with the increased risk of repeat revascularization and myocardial infarction.

Non-infarct related artery revascularization in ST-segment elevation myocardial infarction patients with multivessel disease.

Multivessel disease (MVD) is common in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) and is associated with significant risk of future cardiovascular (CV) events including short and longer-term mortality. In this review, we examine the pathophysiologic construct contributing to adverse prognosis of MVD in STEMI, relevant available evidence that currently guides the management of the noninfarct-related artery (IRA) stenosis and define the remaining knowledge gaps for future studies. Results of recent small sized randomized trials, when pooled, suggest improvement in CV outcomes including CV mortality and repeat revascularization with revascularization of the non-IRA stenosis compared with medical management alone. In addition, there does not appear to be an increase in bleeding, contrast-induced nephropathy or stroke, as suggested by earlier observational data. These recent data have led to a Class IIb recommendation in the American College of Cardiology/American Heart Association guidelines stating that non-IRA revascularization may be considered in selected patients with STEMI and MVD who are hemodynamically stable, either at the time of primary PCI or as a planned staged procedure. The ongoing COMPLETE and CULPRIT-SHOCK studies will provide additional data to further inform the role of non-IRA revascularization and its timing in the management of these patients.

Managing Multivessel Coronary Artery Disease in Patients With ST-Elevation Myocardial Infarction: A Comprehensive Review.

Multivessel coronary artery disease (CAD) is found in up to 60% of the patients presenting with an ST-elevation myocardial infarction (STEMI) and worsens the prognosis proportional to the extent of CAD severity. However, the 2013 American College of Cardiology/American Heart Association STEMI guidelines, based on mostly observational data, had recommended against a routine noninfarct-related artery percutaneous coronary intervention (PCI). After these guidelines were published, a handful of randomized trials became available, and they suggested that PCI of significant lesions in a noninfarct-related artery at the time of primary PCI might result in improved patient outcomes. The incidence of major adverse cardiac events was significantly reduced by 55% at 1 year and 65% at 2 years in patients undergoing angiographically guided PCI of nonculprit vessels at the time of primary PCI, in 2 different randomized trials. Fractional flow reserve-guided PCI of nonculprit vessels in this setting has also been shown to reduce cardiac events by 44% at 1 year. Meta-analyses of both nonrandomized and randomized trials have also suggested that complete revascularization at the time of STEMI significantly improves outcomes, including long-term all-cause mortality. In view of the emerging data, a focused update on primary PCI was published in 2015 and suggested that PCI of noninfarct-related arteries might be considered in selected patients. This article is a comprehensive review of the literature on the treatment of multivessel CAD in patients with STEMI, which provides the reader a critical analysis of the available information to determine the best therapeutic approach.

Fractional Flow Reserve-Guided Complete Revascularization Improves the Prognosis in Patients With ST-Segment-Elevation Myocardial Infarction and Severe Nonculprit Disease: A DANAMI 3-PRIMULTI Substudy (Primary PCI in Patients With ST-Elevation Myocardial Infarction and Multivessel Disease: Treatment of Culprit Lesion Only or Complete Revascularization).

The impact of disease severity on the outcome after complete revascularization in patients with ST-segment-elevation myocardial infarction and multivessel disease is uncertain. The objective of this post hoc study was to evaluate the impact of number of diseased vessel, lesion location, and severity of the noninfarct-related stenosis on the effect of fractional flow reserve-guided complete revascularization. In the DANAMI-3-PRIMULTI study (Primary PCI in Patients With ST-Elevation Myocardial Infarction and Multivessel Disease: Treatment of Culprit Lesion Only or Complete Revascularization), we randomized 627 ST-segment-elevation myocardial infarction patients to fractional flow reserve-guided complete revascularization or infarct-related percutaneous coronary intervention only. In patients with 3-vessel disease, fractional flow reserve-guided complete revascularization reduced the primary end point (all-cause mortality, reinfarction, and ischemia-driven revascularization; hazard ratio [HR], 0.33; 95% confidence interval [CI], 0.17-0.64; P=0.001), with no significant effect in patients with 2-vessel disease (HR, 0.77; 95% CI, 0.47-1.26; P=0.29; P for interaction =0.046). A similar effect was observed in patients with diameter stenosis ≥90% of noninfarct-related arteries (HR, 0.32; 95% CI, 0.18-0.62; P=0.001), but not in patients with less severe lesions (HR, 0.72; 95% CI, 0.44-1.19; P=0.21; P for interaction =0.06). The effect was most pronounced in patients with 3-vessel disease and noninfarct-related stenoses ≥90%, and in this subgroup, there was a nonsignificant reduction in the end point of mortality and reinfarction (HR, 0.32; 95% CI, 0.08-1.32; P=0.09). Proximal versus distal location did not influence the benefit from complete revascularization. The benefit from fractional flow reserve-guided complete revascularization in ST-segment-elevation myocardial infarction patients with multivessel disease was dependent on the presence of 3-vessel disease and noninfarct diameter stenosis ≥90% and was particularly pronounced in patients with both of these angiographic characteristics. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01960933.

Association of red cell distribution width with noninfarct-related artery-chronic total occlusion in acute myocardial infarction patients.

The presence of chronic total occlusion (CTO) in noninfarct-related artery (non-IRA) is an independent predictor of mortality in acute myocardial infarction (AMI). We investigated whether red cell distribution width (RDW) levels are associated with presence of non-IRA-CTO in AMI (ST-elevation myocardial infarction [STEMI] and non-STEMI). Patients (n = 858) were categorized into three groups: single vessel disease, multivessel disease (MVD) without CTO and MVD with CTO. MVD with CTO group had higher RDW levels than single vessel disease and MVD without CTO groups (14.87 ± 1.09% vs 13.82 ± 1.01% and 13.87 ± 0.87%, respectively, p < 0.001). In-hospital mortality was also higher in patients with MVD with CTO (p < 0.001). On multivariate analysis, RDW (odds ratio [OR]: 1.761; p < 0.001), age (OR: 1.04; p < 0.001), creatinine (OR: 3.524; p = 0.027), current smoker (OR: 0.489; p = 0.022), hemoglobin (OR: 0.826; p = 0.044), and non-STEMI (OR: 3.065; p < 0.001) were predictors of occurrence of non-IRA-CTO. Increased RDW is independently associated with presence of non-IRA-CTO in AMI patients.

Comparison of Outcomes of Staged Complete Revascularization Versus Culprit Lesion–Only Revascularization for ST-Elevation Myocardial Infarction and Multivessel Coronary Artery Disease

The management of noninfarct-related arteries in patients with ST-elevation myocardial infarction (STEMI) and multivessel coronary disease (MVD) is still debated. We evaluated the prognostic impact of staged complete revascularization with percutaneous coronary intervention (PCI) in STEMI patients with MVD admitted to our hospital from 2005 to 2013. Patients undergoing staged complete revascularization (n= 300) were compared with 1:1 propensity score-matched patients with culprit lesion-only treatment (n= 300). We considered a composite primary end point of all-cause death, myocardial infarction, and urgent PCI. Secondary end points included components of the primary, cardiovascular death, any PCI excluding staged PCI. We also performed an analysis including only patients surviving at least 5days. The median follow-up was 553days. The primary end point occurred in 10.3% of patients in the staged complete revascularization group and in 16.3% of patients in the culprit lesion-only group (hazard ratio 0.61, 95% CI 0.38 to 0.95, p= 0.031). Although this difference was no longer significant when considering only the survivors at day 5, all-cause and cardiovascular mortalities were still reduced in the staged complete revascularization group. Complete revascularization was associated with a better outcome (hazard ratio 0.35, 95% CI 0.17 to 0.63, p= 0.005) if performed within 30days of STEMI. In conclusion, compared with culprit lesion-only revascularization, in STEMI patients with MVD undergoing primary PCI, an approach of staged complete revascularization was associated with a better outcome.

Medium platelet volume as a noninvasive predictor of chronic total occlusion in non-infarct artery in patients with non-ST-segment elevation myocardial infarction and multivessel coronary artery disease

BackgroundChronic total occlusion (CTO) in a noninfarct-related artery (non-IRA) is an independent predictor of mortality in non-ST elevation myocardial infarction (NSTEMI). Mean platelet volume (MPV) is associated with cardiovascular events in NSTEMI. Little is known about the predictors of non-IRA-CTO in patients with NSTEMI. The purpose of this study was to evaluate the relationship between the presence of non-IRA-CTO with MPV level in patients with NSTEMI and multivessel coronary artery disease (MVCAD). MethodsData of consecutive patients with NSTEMI and MVCAD treated in high-volume PCI center between 2006 and 2012 and included in the prospective registry were divided according to the presence of CTO and analyzed. ResultsIn the group of 685 patients fulfilling the inclusion criteria, 308 (45%) patients had CTO (CTO+), and in 377 (55%) patients CTO was not observed (CTO−). The MPV level on admission was significantly higher in the CTO+ group than in the CTO− group (P<0.0001). In the multivariate analysis of the entire study population, independent predictors of occurrence of CTO were medium platelet volume (MPV; per 1fL more; odds ratio [OR] 1.34; 95% confidence interval [CI] 1.15–1.57; P=0.0002) together with left ventricular ejection fraction and prior MI. ConclusionsMPV at admission is independently associated with more frequent occurrence of non-IRA CTO in patients with NSTEMI and MVCAD.

TCT-149 Impact of Chronic Total Occlusion in a Non-Infarct-related Artery on clinical outcomes in patients undergoing Primary Percutanous Coronary Intervention: analysis of a 8 year-all-comers prospective registry

In the setting of primary percutaneous coronary intervention (PPCI), encountering with chronic total oclussion (CTO) in a noninfarct-related artery (IRA) is not a rare situation. The impact of CTO on clinical outcomes in acute ST-elevation myocardial infarction (STEMI) patients is not well defined.

TCT-188 The impact of the location on left ventricular function in ST-elevation Myocardial Infarction patients with a chronic total occlusion in a non-infarct related artery treated with percutaneous coronary intervention

The optimal treatment for the CTO found during primary PCI in STEMI patients remains unknown and the best strategy may be based on coronary location of the CTO. In this EXPLORE substudy, we evaluated LVEF and LVEDV measured on 4 months cardiac MRI, compared across the different coronary locations

Chronically Occluded Coronary Artery in Patients Undergoing Acute Coronary Syndromes Worsens their Long-Term Prognosis

Background: Comparison of patients with and without chronic total occlusion in a non-infarct related artery (non-IRA) and the coronary artery dominance type in terms of clinical characteristics and impact on the degree of left ventricular dysfunction and long term survival. Material and findings: There were 402 consecutive patients with multi-vessel disease, who had undergone percutaneous coronary intervention because of acute coronary syndrome, enrolled in this study. As many as 33.8% of patients had at least one chronic total occlusion in non-IRA. Left coronary artery dominance was present in 10.95% of patients only, and 83.58% of them showed right coronary artery dominance. Patients with chronic total occlusion were at higher risk because of age and comorbidity. An ST-segment elevation myocardial infarction occurred more often in all patients without chronic total occlusion, while patients with non-IRA chronic total occlusion more frequently presented with an-ST-segment elevation myocardial infarction. No fewer than 48.5% of patients with chronic total occlusion had at least moderate left ventricular dysfunction while in patients without chronic total occlusion the number reached 25.56% only (p = 0.02). No significant differences were observed between patients with right dominance vs left dominance (p = 0.9). The average 466-day mortality in 402 patients with multivessel disease was 13.18%. Among patients with chronic total occlusion, all cause and cardiovascular mortality were 17% and 12.5%, while in patients without chronic total occlusion 11% and 9%, respectively (p = 0.2 and p = 0.4). In patients with left dominance vs right dominance it was 20.5% and 16% vs 13.1% and 9.8%, respectively (p = 0.36 and p = 0.4). Conclusions: The main factor that influences prognosis is the presence of chronic total occlusion in a non-infarct related artery rather than the coronary artery dominance type. However, the presence of left dominance may be an additional adverse cardiovascular risk factor.

Infarct size following complete revascularization in patients presenting with STEMI: a comparison of immediate and staged in-hospital non-infarct related artery PCI subgroups in the CvLPRIT study

BackgroundThe CvLPRIT study showed a trend for improved clinical outcomes in the complete revascularisation (CR) group in those treated with an immediate, as opposed to staged in-hospital approach in patients with multivessel coronary disease undergoing primary percutaneous intervention (PPCI). We aimed to assess infarct size and left ventricular function in patients undergoing immediate compared with staged CR for multivessel disease at PPCI.MethodsThe Cardiovascular Magnetic Resonance (CMR) substudy of CvLPRIT was a multicentre, prospective, randomized, open label, blinded endpoint trial in PPCI patients with multivessel disease. These data refer to a post-hoc analysis in 93 patients randomized to the CR arm (63 immediate, 30 staged) who completed a pre-discharge CMR scan (median 2 and 4 days respectively) after PPCI. The decision to stage non-IRA revascularization was at the discretion of the treating interventional cardiologist.ResultsPatients treated with a staged approach had more visible thrombus (26/30 vs. 31/62, p = 0.001), higher SYNTAX score in the IRA (9.5, 8–16 vs. 8.0, 5.5–11, p = 0.04) and a greater incidence of no-reflow (23.3 % vs. 1.6 % p < 0.001) than those treated with immediate CR. After adjustment for confounders, staged patients had larger infarct size (19.7 % [11.7–37.6] vs. 11.6 % [6.8–18.2] of LV Mass, p = 0.012) and lower ejection fraction (42.2 ± 10 % vs. 47.4 ± 9 %, p = 0.019) compared with immediate CR.ConclusionsOf patients randomized to CR in the CMR substudy of CvLPRIT, those in whom the operator chose to stage revascularization had larger infarct size and lower ejection fraction, which persisted after adjusting for important covariates than those who underwent immediate CR. Prospective randomized trials are needed to assess whether immediate CR results in better clinical outcomes than staged CR.Trial registrationISRCTN70913605, Registered 24th February 2011.

TCT-8 First results of the EXPLORE trial, a Global, Randomized, Prospective, Multicenter Trial Investigating the Impact of Recanalization of a Chronic Total Occlusion on Left Ventricular Function in Patients after Primary Percutaneous Coronary Intervention for Acute ST-Elevation Myocardial Infarction

In the setting of primary percutaneous coronary intervention (PPCI), patients with a concurrent chronic total occlusion (CTO) in a non-infarct related artery (IRA) were recently identified as a high-risk subgroup. It is unclear whether ST-elevation myocardial infarction (STEMI) patients with a CTO

Management of Multivessel Coronary Disease in ST-segment Elevation Myocardial Infarction.

Primary PCI of infarct-related arteries is the preferred reperfusion strategy in patients presenting with ST-segment elevation myocardial infarction (STEMI). Up to 40 % of such patients demonstrate evidence of multivessel, non-infarct-related artery coronary disease. Previous non-randomised observational studies and their associated meta-analyses have suggested that in such cases only the culprit infarct-related artery (IRA) lesion should be treated. However, recent randomised controlled trials have demonstrated improved clinical outcomes with lower major adverse cardiovascular events (MACE) rates when complete revascularisation is undertaken either at index primary percutaneous coronary intervention (PPCI) or during index admission. These trials suggest that current guidelines pertaining to treatment of non-infarct-related artery (N-IRA) lesions in STEMI patients with multivessel disease may need to be reconsidered depending on future trials. However, issues remain around timing of N-IRA intervention, the use of fractional flow reserve (FFR) or intravascular imaging to guide intervention in N-IRA lesions and the need to demonstrate reductions in hard clinical endpoints (death and MI) after complete revascularisation; these issues will need to be addressed through future trials. Clinicians must judge on the currently available data, whether it is still safer to leave important stenosis in N-IRA untreated.