Original title: Acute multivessel revascularization improves 1 year outcomes in ST-elevation myocardial infarction. A nationwide study from AMIS plus registry. Reference: Raban Jeger, et al. International journal of Cardiology 2014;172:76-81
The presence of multiple vessel lesions is present in about 50% of patients referred for primary angioplasty. The accepted strategy is to treat the culprit artery even though there are not sufficient studies regarding the when and how to treat other arteries with severe injuries. 1909 patients in the National Myocardial Infarction Register of Switzerland were admitted experiencing a ST segment elevation myocardial infarction and had multivessel disease, of whom 442 (23 %) had multivessel angioplasty and 1467 (77%) only responsible vessel angioplasty.
The primary end point of the study was death from any cause and the secondary, a composite of death, myocardial reinfarction, rehospitalization for cardiac causes, and any heart reintervention and stroke. Both populations’ characteristics were similar with the exception of increased cerebrovascular disease in a group where only culprit vessel was treated, and a major Killip class in the group treated for multiple vessels. In both, medical treatment at discharge was similar. With a median follow-up of 378 days, death for any cause (primary end point) was identical in both groups (2.7%, P> 0.99) unlike the combined secondary end point that was significantly lower in those with multivessel angioplasty (15.6% versus 20%, p = 0.038). This difference was based on the rehospitalizations and reinterventions and not in deaths or reinfarctions. Those who received drug-eluting stent angioplasty to multivessel had lower mortality (2.1 % versus 7.4%, P = 0.026) and lower combined events (14.1% versus 25.9%, p = 0.042) compared with those receiving conventional stents and this benefit was maintained beyond two years.
Conclusion
In a population unselected from a real world, an immediate complete revascularization strategy may be beneficial during primary angioplasty considering the combined events and especially using drug-eluting stents. This should be tested in randomized trials.
Comment
The strategy of performing a multi-vessel angioplasty during primary angioplasty has been demonstrated already in several studies as feasible, safe, and that reduces the event rate, primarily due to the lower rate of reinterventions and rehospitalizations. The use of DES has also proven to be safe and beneficial. It would be important to conduct larger controlled studies to identify the groups that benefit most from this strategy.
Courtesy of Dr. Carlos Fava
Interventional cardiologist
Favaloro Foundation – Argentina
Dr. Carlos Fava para SOLACI.ORG