Best Strategy for Acute MI and Multivessel Disease

The goal of this study was to assess all available revascularization strategies for patients undergoing ST elevation acute myocardial infarction and multivessel disease.

Among the strategies to treat this group of patients, there were:

• culprit vessel intervention only,
• culprit vessel intervention and, in case of success, multivessel intervention,
• culprit vessel intervention with staged revascularization, within the same hospitalization period.

These three strategies were compared in 6,503 patients with STEMI and multivessel disease enrolled in the British Columbia registry between 2008 and 2014. The study assessed all-cause mortality and repeat revascularization at 2 years.

Both culprit vessel intervention (HR: 0.78; CI 95%: 0.64 to 0.97; p=0.023) and staged revascularization (HR: 0.55; CI 95%: 0.36 to 0.82; p=0.004) showed lower mortality when compared to multivessel intervention at primary PCI.

Culprit vessel intervention only showed higher repeat revascularization rate when compared with multivessel intervention (HR: 1.25; CI 95%: 1.02 to 1.54; p=0.036) and staged revascularization (HR: 0.64; CI 95%: 0.46 to 0.90; p=0.012).

Conclusion

In patients undergoing ST elevation acute myocardial infarction with multivessel disease, culprit vessel intervention followed by staged multivessel revascularization showed lower mortality and repeat revascularization rates. These findings call for a prospective evaluation of randomized studies with adequate statistical power.

Editorial Comment

Both strategies of culprit vessel intervention (with or without following multivessel intervention) were associated to lower mortality compared to multivessel intervention, as long as the non-culprit arteries were the right coronary and left circumflex arteries.

Revascularization of the non-culprit left anterior descending artery at primary PCI did show the same benefits.

Original Title: Culprit Vessel versus Multivessel versus In-Hospital Staged Intervention for Patients with ST-Segment Elevation Myocardial Infarction and Multivessel Disease. Stratified Analyses in High-Risk Patient Groups and Anatomic Subsets of Non-culprit Disease.

Reference: M. Bilal Iqbal et al. J Am Coll Cardiol Intv 2017;10:11–23.

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