Percutaneous coronary intervention (PCI) is considered the treatment of choice in ST-segment elevation myocardial infarction (STEMI). However, it is widely acknowledged that, in many cases, there are significant lesions in other coronary arteries. Previous randomized studies have shown that complete revascularization in a second procedure is more beneficial than intervention only in the culprit artery.
However, there is still no conclusive evidence to support PCI in the other coronary arteries during the same procedure.
The MULTISTAR Trial addressed this issue by including 840 patients with STEMI who were hemodynamically stable and had lesions in multiple coronary vessels. Of these patients, 418 underwent primary PCI along with immediate PCI of severe lesions in other coronary arteries (PCI I), while 422 underwent PCI only in the culprit artery, deferring intervention in severe lesions in the rest of the vessels (PCI D). This second intervention took place between day 19 and day 45 after the event. It is worth noting that researchers used third-generation SYNERGY stent, from Boston Scientific.
The primary endpoint (PEP) of the MULTISTAR Trial consisted of a set of events that included death from any cause, non-fatal acute myocardial infarction, stroke, unplanned revascularization due to ischemia, or hospitalization for heart failure within one year from randomization.
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The average age of the participants was 75 years, and most of them were men. Additionally, 50% of patients had hypertension, 15% had diabetes, 6% had undergone a prior PCI, 5% had experienced a prior acute myocardial infarction, 2% had suffered a stroke, 2% had peripheral vascular disease, and 4% had experienced cardiac arrest before arriving at the hospital.
The most common location of acute myocardial infarction was the anterior region (40%), followed by the inferior (11%), lateral, and posterior.
Transradial access was the most frequently used (72%). There were no significant differences between the two groups regarding the procedure, the culprit artery, the lesions in multiple vessels, or the stents used. The use of intravascular imaging techniques (IVUS, OCT) or the assessment of coronary physiology were infrequent.
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Regarding the primary endpoint at 12 months, PCI I was not inferior to PCI D as a strategy. The event rate was 8.5% in the PCI I group and 13.6% in the PCI D group, with a hazard ratio of 0.52 (95% confidence interval, 0.38 to 0.72; p < 0.001 for non-inferiority and p < 0.001 for superiority). Additionally, there were no significant differences in terms of all-cause death, non-fatal acute myocardial infarction, stroke, ischemia-guided revascularization, or hospitalization for heart failure between the two groups.
Conclusion
In summary, in hemodynamically stable patients with AMI and lesions in multiple coronary arteries, immediate PCI was not inferior compared with its deferral, in terms of all-cause death, non-fatal acute 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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