The presence of lesions in multiple vessels is common in ST-segment elevation myocardial infarction (STEMI). It has been shown that, when they are treated in a second procedure, patients have a better outcome.
To date, there is limited information available on percutaneous transluminal coronary angioplasty (PTCA) in vessels with severe non-culprit lesions during primary angioplasty. This is due to speculation that prolonging the procedure could add comorbidities, especially in terms of renal failure, or (in the case of complications during PTCA of the non-culprit artery) jeopardize the patient.
The MULTISTAR AMI Study is a randomized, multicenter trial that included 840 patients with STEMI. Of these, 418 underwent immediate PTCA of the non-culprit vessel (Immediate PTCA) and 422 underwent deferred PTCA of the non-culprit vessel (Deferred PTCA) between 19 and 45 days after the event.
The primary endpoint (PEP) was defined as all-cause death, non-fatal myocardial infarction, stroke, ischemia-guided revascularization, or hospitalization for heart failure within one year from randomization.
Both groups were similar in terms of demographic characteristics. The mean age was 65 years, and approximately 80% of patients were men; 15% had diabetes, 52% had hypertension, 7% had undergone a prior PTCA, 5% had had a prior MI, and 2% had had a stroke.
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The most common type of MI was anterior (40%), followed by inferior, lateral, and posterior.
In 72% of cases, PTCA was performed via transradial access, and fractional flow reserve (FFR) or imaging was used during the procedure in a low proportion. Crossover was required in 2.9% of cases in the Deferred PTCA group. The average length of hospital stay was 4 days.
The PEP was similar in both groups: 8.5% in the Immediate PTCA arm and 16.5% in the Deferred PTCA group. There was no evidence of inferiority between the two strategies (hazard ratio, 0.52; 95% confidence interval [CI], 0.38 to 0.72; P <0.001 for non-inferiority and P <0.001 for superiority).
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There were no significant differences in all-cause mortality, cardiovascular mortality, stroke, non-fatal MI, ischemia-guided revascularization, stent thrombosis, bleeding, hospitalization for heart failure, worsening of renal function, or worsening quality of life.
Conclusion
In hemodynamically stable patients with STEMI and lesions in multiple coronary vessels, immediate multivessel PTCA was non-inferior to the staged approach in terms of the risk of all-cause death, non-fatal myocardial infarction, stroke, ischemia-guided revascularization, or hospitalization for heart failure during a one-year period.
Dr. Carlos Fava.
Member of the Editorial Board of SOLACI.org.
Original Title: Timing of Complete Revascularization with Multivessel PCI for Myocardial Infarction.
Reference: B.E. Stähli, et al. NEJM DOI: 10.1056/NEJMoa2307823.
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