Gentileza del Dr. Javier Castro
In the daily practice, a high percentage of ST elevation myocardial infarction patients (STEMI) present multivessel disease (40-65%). This group of patients presents worse clinical evolution and higher mortality than patients with one culprit lesion.
When PCI is indicated to a patient with significant lesions in more than one vessel, we can choose to follow different strategies:
- Treat the culprit vessel and clinically assess the need to treat the other vessels
- Treat the culprit and non-culprit vessels with significant lesions during the same procedure
- Treat the culprit vessel and defer the treatment of non-culprit vessels with significant lesions
According to the European Cardiology Society guidelines, we should perform multivessel PCI during STEMI in case of cardiogenic shock or unstable plaque with persistent ischemia after successful PCI to the culprit vessel.
Given the limited number of prospective studies ─ mostly of poor statistical power and focused mainly on combined end points, mainly the need of repeat revascularization and not mortality ─ Dr. Tarantini el al. carried out the present meta-analyzis of the most important studies, including more than 54,000 patients.
Studies on Multivessel PCI between 2001 and 2015 were analyzed.
32 studies were selected: 13 prospective and 19 retrospective, including a total of 54,148 patients.
Primary end point was all cause mortality at short and long term.
These patients were sorted as follows:
- Infarct-related artery only (IRA-PCI): 42,112 patients
- Single multivessel procedure (MV-PCI): 8,138 patients
- Infarct related PCI + deferred multivessel PCI (Staged MV-PCI): 3,898 patients
[Staged MV-PCI was performed during hospitalization and up to 2 months after IRA-PCI.
Results
- Short term mortality showed patients undergoing staged MV PCI presented lower mortality compared to IRA patients (1.9% vs 4.9%; p= 0.002) and MV PCI (1.4% vs5.6%; p= <0.0001).
- The study also showed lower mortality in the ARI group when compared to MV PCI (6.9% vs 8.0%; p=0.04).
- Long term mortality showed that patients undergoing staged MV PCI showed lower mortality compared to ARI (4.1% vs 6.8%; p= 0.001) and MV PCI (3.1% vs 8.5%; p= <0.0001).
- When patients with cardiogenic shock were excluded, staged MV PCI maintained lower mortality at short and long term
- In the subgroup of diabetic patients: the higher the rate of multivessel disease, the higher the survival at long term in the staged MV PCI group.
Conclusion
Infarct related artery PCI was associated with higher survival at short term compared to complete revascularization during primary PCI.
Staged revascularization had lower mortality at short and long term than infarct related PCI and complete revascularization during primary PCI.
It seems the higher the number of compromised vessels, the higher the benefit of complete revascularization.
Editorial Comment
The idea of limiting PCI to the culprit vessel in STEMI patients has been questioned since the PRAMI study, which showed a significant difference in hard events in favor of complete revascularization during primary PCI.
Two years later, the CULPRIT study was published and, as the latter, it compares both strategies, though complete revascularization was done in 60% of patients at primary PCI, and the rest had deferred procedures. In this study, there was a difference in combined end point, and not in hard events.
The PRIMULTI study, where complete revascularization was staged and FFR guided, only showed significant differences in the combined end point, driven by less need of revascularization, even though 40% of these were emergency procedures.
The present meta-analyzis considers these and other studies and analyzes mortality at short and long term as end point. Outcomes should take into account the high heterogeneity rate, given the use of retrospective registries.
The three strategies, compared for both short and long term mortality, result in different outcomes when looking at prospective and retrospective studies, or complete and staged revascularization, so these variables should be taken into account, in addition to the elevated use of IIb-IIIa glycoprotein inhibitors in most studies.
Finally, we should remember that after the 2015 update, the American guidelines no longer indicate against complete revascularization strategies, both immediate and staged: they now have a IIb recommendation with evidence level b.
Courtesy of Dr. Javier Castro. San Juan de Dios Hospital, Ramos Mejía, Argentina.
Original Title: Survival after varying revascularization strategies in patients with ST- segment elevation myocardial infarction and multivessel coronary artery disease. A Pairwise and Network Meta-Analysis.
Reference: Tarantini et al. J Am Coll Cardiol Intv 2016;9:1765-76.
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