Multivessel Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction With Cardiogenic Shock

Background

Recent trials demonstrated a benefit of multivessel percutaneous coronary intervention (PCI) for noninfarct-related artery (non-IRA) stenosis over IRA-only PCI in patients with ST-segment elevation myocardial infarction (STEMI) multivessel disease. However, evidence is limited in patients with cardiogenic shock.

Complete Revascularization Versus Culprit Lesion Only in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Disease: A DANAMI-3–PRIMULTI Cardiac Magnetic Resonance Substudy

Objectives

The aim of this study was to evaluate the effect of fractional flow reserve (FFR)–guided revascularization compared with culprit-only percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) on infarct size, left ventricular (LV), function, LV remodeling, and the presence of nonculprit infarctions.

Culprit Vessel Only Versus “One-week” Staged Percutaneous Coronary Intervention for Multivessel Disease in Patients Presenting with ST-Segment Elevation Myocardial Infarction

Objective To explore the impact of a “one-week” staged multivessel percutaneous coronary intervention (PCI) versus culprit-only PCI on deaths and major adverse cardiac events (MACE). Methods We retrospectively analyzed 447 patients with multivessel disease who experienced a ST-segment elevation myocardial infarction (STEMI) within 12 h before undergoing PCI between July 26, 2008 and September 25, 2011. After completion of PCI in the infarct artery, 201 patients still in the hospital agreed to undergo PCI in non-infarct arteries with more than 70% stenosis for a “one-week” staged multivessel PCI. A total of 246 patients only received intervention for the culprit vessel. Follow-up ended on September 9, 2014. This study examined the differences in deaths from any cause (i.e., cardiac and noncardiac) and MACE between the two treatment groups. Results Compared to a culprit-only PCI treatment approach, the “one-week” staged multivessel PCI was strongly associated with greater benefits for 55-month all cause death [41 (16.7%) vs. 13 (6.5%), P = 0.004] and MACE [82 (33.3%) vs. 40 (19.9%), P = 0.002] rates. In addition, there were significant differences in the number of myocardial infarctions [43 (17.5%) vs. 20 (10.0%), P = 0.023], coronary-artery bypass grafting [CABG; 20 (8.1%) vs. 6 (3.0%), P = 0.021], and PCI [31 (12.6%) vs. 12 (6.0%), P = 0.018]. Patients undergoing culprit-only PCI compared to “one-week” PCI had the same number of stent thrombosis events [7 (2.8%) vs.3 (1.5%), P = 0.522]. Conclusions Compared to a culprit-only PCI treatment approach, “one-week” staged multi-vessel PCI was a safe and effective selection for STEMI and multi-vessel PCI.     

Impact of diabetes on long-term outcome in STEMI patients undergoing primary angioplasty with glycoprotein IIb–IIIa inhibitors and BMS or DES

Diabetes has been shown to be associated with worse survival and repeat revascularization (TVR) after primary angioplasty. Drug-eluting stent (DES) may offer benefits in terms of TVR, that may be counterbalanced by an higher risk of stent thrombosis, especially among STEMI patients. Aim of the current study was to evaluate the impact of diabetes on 5-year outcome in patients undergoing primary angioplasty with Glycoprotein IIb–IIIa inhibitors in the era of DES. Our population is represented by STEMI patients undergoing primary angioplasty and stent implantation at a tertiary center with 24-h primary PCI capability within 12 h of symptom onset. All patients received glycoprotein IIb–IIIa inhibitors. No patient was lost to follow up. From 2003 to 2005, 270 STEMI patients were treated with DES (n = 180), or BMS (n = 90). A total of 69 patients had history of diabetes at admission (25.5%). At a follow-up of 1510 ± 406 days, diabetes was associated with a higher rate of death (29.5 vs. 5.1%, P < 0.0001), reinfarction (24.1 vs. 9.1%, P < 0.0001), TVR (19.1 vs. 13.1%, P = 0.052), IST (17.2 vs. 6.8%, P < 0.001) and MACE (51.9 vs. 25.1%, P < 0.001). These results were confirmed in both patients receiving BMS or DES, except for TVR, where no difference was observed between diabetic and non-diabetic patients. This study shows that among STEMI patients undergoing primary angioplasty with Gp IIb–IIIa inhibitors, diabetes is associated with worse long-term mortality, reinfarction, and IST, even with DES implantation, that, however, were able to equalize the outcome in terms of TVR as compared to non diabetic patients.     

Validation of Scoring Systems That Predict Outcomes in Patients With Coronary Artery Disease Undergoing Coronary Artery Bypass Grafting Surgery

Several risk stratification scores, based on angiographic or clinical parameters, have been developed to evaluate outcomes in patients with left main coronary artery disease (LMCAD) who undergo coronary artery bypass grafting (CABG). This study aims to validate the predictive ability of different risk scoring systems with regard to long-term outcomes after CABG.This single-center study retrospectively re-evaluated the Synergy Between PCI with TAXUS and Cardiac Surgery (SYNTAX) score; EuroSCORE; age, creatinine, and ejection fraction (ACEF) score; modified ACEF score; clinical SYNTAX; logistic clinical SYNTAX score (logistic CSS); and Parsonnet scores for 305 patients with LMCAD who underwent CABG. The endpoints were 5-year rate of all-cause death and major adverse cardio-cerebral events (MACCEs), including cardiovascular (CV) death, myocardial infarction (MI), and stroke and target vessel revascularization (TVR).Compared with the SYNTAX score, other scores were significantly higher in discriminative ability for all-cause death (SYNTAX vs others: P < 0.01). The EuroSCORE ≥6 showed significant outcome difference on all-cause death, CV death, MI, and MACCE (P < .01). Multivariate analysis indicated the SYNTAX score was a non-significant predictor for different outcomes. Adjusted multivariate analysis revealed that the EuroSCORE was the strongest predictor of all-cause death (hazard ratio[HR]: 1.17; P < 0.001), CV death (HR: 1.16; P < 0.001), and MACCE (HR: 1.09; P = 0.01). The ACEF score and logistic CSS were predictive factors for TVR (HR: 0.25, P = 0.03; HR: 0.85, P = 0.01).The EuroSCORE scoring system most accurately predicts all-cause death, CV death, and MACCE over 5 years, whereas low ACEF score and logistic CSS are independently associated with TVR over the 5-year period following CABG in patients with LMCAD undergoing CABG.     

In unstable angina or non-ST-segment acute coronary syndrome, should patients with multivessel coronary artery disease undergo multivessel or culprit-only stenting?

OBJECTIVES: We examined the safety and efficacy of nonculprit multivessel compared with culprit-only stenting in patients with multivessel disease presenting with unstable angina or non-ST-segment elevation myocardial infarction (non-ST-segment elevation acute coronary syndromes [NSTE-ACS]). BACKGROUND: In patients presenting with NSTE-ACS, multivessel coronary artery disease (CAD) is associated with adverse outcome. METHODS: Patients with multivessel CAD and NSTE-ACS that underwent percutaneous coronary intervention were included. The culprit lesion was defined by reviewing each patient's angiographic report, electrocardiogram, echocardiogram and, if available, nuclear stress test. All patients had at least 2 vessels with > or =50% stenosis, and the angiographic severity of CAD was assessed using the Duke Prognostic Angiographic Score. Patients with coronary bypass grafts, chronic total occlusions, and those with uncertain culprit lesions were excluded. Our end point was the composite of death, myocardial infarction, or any target vessel revascularization. RESULTS: From January 1995 to June 2005, 1,240 patients with ACS and multivessel CAD underwent percutaneous coronary intervention with bare-metal stenting and met our study criteria. Of these, 479 underwent multivessel and 761 underwent culprit-only stenting. There were 442 events during a median follow-up of 2.3 years. Multivessel intervention was associated with lower death, myocardial infarction, or revascularization after both adjusting for baseline and angiographic characteristics (hazard ratio 0.80; 95% confidence interval 0.64 to 0.99; p = 0.04) and propensity matched analysis (hazard ratio 0.67; 95% confidence interval 0.51 to 0.88; p = 0.004). CONCLUSIONS: In patients with multivessel CAD presenting with NSTE-ACS, multivessel intervention was significantly associated with a lower revascularization rate, which translated to a lower incidence of the composite end point compared with culprit-only stenting.     

Meta-analysis of percutaneous coronary intervention versus coronary artery bypass graft surgery in patients with diabetes and left main and/or multivessel coronary artery disease

The optimal coronary revascularization strategy for patients with diabetes and left main and/or multivessel disease is undetermined. The aim of our study was to evaluate percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) in those patients. We identified 13 articles, published before October 2011, enrolling 6992 patients, whose follow-up period ranged from 1 to 5 years. Patients with PCI had a significant reduction in cerebral vascular attack (CVA) (OR, 0.29; 95 % CI, 0.16–0.51; p < 0.0001, I ² = 0 %) as compared with CABG, whereas there was a fourfold increased risk of repeat revascularization associated with PCI even using drug-eluting stent (OR, 4.44; 95 % CI, 3.42–5.78; Χ² = 4.92, p < 0.00001, I ² = 0 %). The overall mortality (OR, 0.97; 95 % CI, 0.81–1.15; p = 0.70, I ² = 0 %) was comparable between the PCI and CABG. However, in subgroup analysis, the composite outcome (death/myocardial infarction/CVA) was significantly reduced in favor of DES implantation (OR, 0.79; 95 % CI, 0.63–0.99; Χ² = 1.07, p = 0.04, I ² = 0 %). Our study confirmed the cerebral vascular benefits of PCI by significantly reducing CVA risks, and the composite outcome was better in patients undergoing PCI with drug-eluting stent, despite a higher repeat revascularization rate. It poses imperative demands for future prospective randomized studies to define the optimal strategy in patients with diabetes and left main and/or multivessel disease.     

Does Proximal Location of Culprit Lesion Confer Worse Prognosis in Patients Undergoing Primary Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction?

ST segment elevation myocardial infarction (STEMI) from proximally located culprit lesion is associated with greater myocardium at jeopardy. In STEMI patients treated with thrombolytics, proximal culprit lesions are known to have worse prognosis. This relation has not been studied in patients undergoing primary percutaneous coronary intervention (PCI). In 3,535 STEMI patients with native coronary artery occlusion pooled from the primary angioplasty in myocardial infarction database, we compared in-hospital and 1-year outcomes between those with proximal (n = 1,606) versus non-proximal (n = 1,929) culprit lesions. Patients with proximal culprits were more likely to die and suffer major adverse cardiovascular events (MACE) during the index hospital stay (3.8% vs 2.2%, P = 0.006; 8.2% vs 5.8%, P = 0.0066, respectively) as well as during 1-year follow-up (6.9% vs 4.5%, P = 0.0013; 22% vs 17%, P = 0.003, respectively) compared to those with non-proximal culprits. After adjustment for baseline differences, proximal culprit was independently predictive of in-hospital death (adjusted odds ratio% 1.58, 95% confidence intervals, CI 1.05-2.40) and MACE (OR 1.41, CI 1.06-1.86), but not 1-year death or MACE. In addition, proximal culprit was independently associated with higher incidence of ventricular arrhythmias and sustained hypotension during the index hospitalization. The univariate impact of proximal culprit lesion on in-hospital death and MACE was comparable to other adverse angiographic characteristics, such as multivessel disease and poor initial thrombolysis in myocardial infarction flow, and greater than that of anterior wall STEMI. In conclusion, proximal location of the culprit lesion is a strong independent predictor of worse in-hospital outcomes in patients with STEMI undergoing primary PCI.     

Clinical Outcomes of Revascularization Strategies for Patients With MVD/LMCA Disease: A Systematic Review and Network Meta-Analysis

Hybrid coronary revascularization (HCR), a new minimally invasive procedure for patients requiring revascularization for multivessel coronary lesions, combines coronary artery bypass grafting (CABG) for left anterior descending (LAD) lesions and percutaneous coronary intervention (PCI) for non-LAD coronary lesions. However, available data related to outcomes comparing the 3 revascularization therapies is limited to small studies.We conducted a search in MEDLINE, EMBASE, and the Cochrane Library of Controlled Trials up to December 31, 2014, without language restriction. A total of 16 randomized trials (n=4858 patients) comparing HCR versus PCI or off-pump CABG (OPCAB) were included in this meta-analysis. The primary outcomes were major adverse cardiac and cerebrovascular events (MACCE), all-cause death, myocardial infarction (MI), cerebrovascular events (CVE), and target vessel revascularization (TVR). Odds ratios (OR) and 95% confidence intervals (CI) were calculated using random-effect and fixed-effect models. Ranking probabilities were used to calculate a summary numerical value: the surface under the cumulative ranking (SUCRA) curve.No significant differences were seen between the HCR and PCI in short term (in hospital and 30 days) with regard to MACCE (odds ratio [OR] = 0.51, 95% confidence interval [CI] 0.00–2.35), all-cause death (OR = 2.09, 95% CI 0.34–7.66), MI (OR = 1.02, 95% CI 0.19–2.95), CVE (OR = 4.45, 95% CI 0.39–19.16), and TVR (OR = 6.99, 95% CI 0.17–39.39). However, OPCAB had lower MACCE than HCR (OR = 0.19, 95% CI 0.00–0.95). In midterm (1 year and 3 year), in comparison with HCR, PCI had higher all-cause death (OR = 5.66, 95% CI 0.00–13.88) and CVE (OR = 4.40, 95% CI 0.01–5.68), and lower MI (OR = 0.51, 95% CI 0.00–2.86), TVR (OR = 0.53, 95% CI 0.05–2.26), and thus the MACCE (OR = 0.51, 95% CI 0.00–2.35). Off-pump CABG presented a better outcome than HCR with significant lower MACCE (OR = 0.17, 95% CI 0.01–0.68). Surface under the cumulative ranking probabilities showed that HCR may be the superior strategy for MVD and LMCA disease when regarded to MACCE (SUCRA = 0.84), MI (SUCRA = 0.76) in short term, and regarded to MACCE (SUCRA = 0.99), MI (SUCRA = 0.94), and CVE (SUCRA = 0.92) in midterm.Hybrid coronary revascularization seemed to be a feasible and acceptable option for treatment of LMCA disease and MVD. More powerful evidences are required to precisely evaluate risks and benefits of the 3 therapies for patients who have different clinical characteristics.     

Platelet Reactivity and Clinical Outcomes After Drug-Eluting Stent Implantation: Results From the PTRG-DES Consortium

BackgroundThe long-term prognostic implication of platelet reactivity after percutaneous coronary intervention (PCI) is not clearly known.ObjectivesThe impacts of platelet reactivity from the PTRG-DES consortium were assessed.MethodsThe primary endpoint was the major adverse cardiac and cerebrovascular events (MACCE) including all-cause death, myocardial infarction, stent thrombosis, or stroke. Key secondary endpoints were all-cause mortality, major bleeding, and net adverse clinical events (NACE), including MACCE and bleeding.ResultsBetween 2003 and 2018, a total of 11,714 patients were enrolled and grouped into tertiles according to P2Y₁₂ reaction units (PRUs): high PRUs (≥253), intermediate PRUs (188-252), and low PRUs (<188). The Kaplan-Meier (KM) estimates of the primary outcome were significantly different across the groups; the high-PRU group showed the highest MACCE rate at 5 years (12.9%, 11.1%, and 7.0% in high-, intermediate-, and low-PRU groups, respectively; P < 0.001), as well as at 1 year (P < 0.001). The high-PRU group had the greatest KM estimates of all-cause death (8.2%, 5.9%, and 3.7%, respectively; P < 0.001) at 5 years without significant differences of major bleeding, and resultant of a higher KM estimates of NACE (15.7%, 13.6%, and 9.7%, respectively; P < 0.001). A PRU ≥252, the best cutoff value, was strongly related to MACCE (HR: 1.39; 95% CI: 1.11-1.74; P = 0.003) and all-cause death at 5 years after PCI (HR: 1.42; 95% CI: 1.04-1.94; P = 0.026). The optimal cutoff value of aspirin reaction units predicting the MACCE occurrence was ≥414 and was significantly associated with 5-year MACCE occurrence or all-cause death (P < 0.001).ConclusionsIn this large-scale cohort, high PRU was significantly associated with occurrence of MACCE, all-death death, and NACE at 5 years, as well as 1 year after PCI. (PTRG-DES Consortium [PTRG]; NCT04734028)     

FFR- Versus Angiography-Guided Revascularization for Nonculprit Stenosis in STEMI and Multivessel Disease: A Network Meta-Analysis

ObjectivesThe aim of this study was to examine the efficacy and safety of fractional flow reserve (FFR)–guided versus angiography-guided approaches for nonculprit stenosis among patients with acute ST-segment elevation myocardial infarction (STEMI) and multivessel disease.BackgroundThe optimal strategy to guide revascularization of nonculprit stenosis among patients with STEMI and multivessel disease remains uncertain.MethodsElectronic databases were searched for randomized trials evaluating the outcomes of culprit-only revascularization, angiography-guided complete revascularization (CR), or FFR-guided CR. A pairwise meta-analysis comparing CR versus culprit-only revascularization and a network meta-analysis comparing the different revascularization techniques were conducted. The primary outcome was major adverse cardiac events (MACE).ResultsThe analysis included 11 trials with 8,195 patients. CR (ie, angiography-guided or FFR-guided CR) was associated with a lower incidence of MACE (odds ratio [OR]: 0.46; 95% CI: 0.35 to 0.59), cardiovascular mortality (OR: 0.63; 95% CI: 0.41 to 0.98), recurrent myocardial infarction (OR: 0.67; 95% CI: 0.48 to 0.95), and repeat ischemia-driven revascularization (OR: 0.26; 95% CI: 0.19 to 0.35). Network meta-analysis demonstrated that the incidence of MACE was lower with both angiography-guided CR (OR: 0.43; 95% CI: 0.31 to 0.58) and FFR-guided CR (OR: 0.52; 95% CI: 0.35 to 0.78) compared with a culprit-only approach, while there was no difference in risk for MACE between angiography-guided and FFR-guided CR (OR: 0.81; 95% CI: 0.51 to 1.29).ConclusionsAmong patients with STEMI and multivessel disease, CR, with angiographic or FFR guidance for nonculprit stenosis, was associated with lower incidence of adverse events compared with culprit-only revascularization. FFR-guided CR was not superior to angiography-guided CR in reducing the incidence of adverse events. Future studies investigating other tools to risk-stratify nonculprit stenoses are encouraged.     

Validating the EXCEL hypothesis: A propensity score matched 3‐year comparison of percutaneous coronary intervention versus coronary artery bypass graft in left main patients with SYNTAX score ≤32

Objectives : The aim of this study is to verify the study hypothesis of the EXCEL trial by comparing percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) in an EXCEL‐like population of patients. Background : The upcoming EXCEL trial will test the hypothesis that left main patients with SYNTAX score ≤32 experience similar rates of 3‐year death, myocardial infarction (MI), or cerebrovascular accidents (CVA) following revascularization by PCI or CABG. Methods : We compared the 3‐year rates of death/MI/CVA and death/MI/CVA/target vessel revascularization (MACCE) in 556 patients with left main disease and SYNTAX score ≤32 undergoing PCI (n = 285) or CABG (n = 271). To account for confounders, outcome parameters underwent extensive statistical adjustment. Results : The unadjusted incidence of death/MI/CVA was similar between PCI and CABG (12.7% vs. 8.4%, P = 0.892), while MACCE were higher in the PCI group compared to the CABG group (27.0% vs. 11.8%, P < 0.001). After propensity score matching, PCI was not associated with a significant increase in the rate of death/MI/CVA (11.8% vs. 10.7%, P = 0.948), while MACCE were more frequently noted among patients treated with PCI (28.8% vs. 14.1%, P = 0.002). Adjustment by means of SYNTAX score and EUROSCORE, covariates with and without propensity score, and propensity score alone did not change significantly these findings. Conclusions : In an EXCEL‐like cohort of patients with left main disease, there seems to be a clinical equipoise between PCI and CABG in terms of death/MI/CVA. However, even in patients with SYNTAX score ≤32, CABG is superior to PCI when target vessel revascularization is included in the combined endpoint. © 2011 Wiley‐Liss, Inc.     

Recanalization of Chronic Total Occlusions in Patients With vs Without Chronic Kidney Disease: The Impact of Contrast-Induced Acute Kidney Injury

Background

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with high contrast volumes, which can be particularly deleterious in patients with chronic kidney disease (CKD). We aimed to study the outcomes of CTO PCI in subjects with vs without CKD, and the impact of contrast-induced acute kidney injury (CI-AKI).

Comparing the use of cobalt chromium stents to stainless steel stents in primary percutaneous coronary intervention for acute myocardial infarction: A prospective registry

Objectives: To determine clinical outcome and rates of target vessel revascularization (TVR) in patients undergoing primary percutaneous coronary intervention (PCI) for STEMI who were treated with cobalt-chromium stents compared to stainless steel bare metal stents (BMS).

Background: The newer generation cobalt chromium stents were reported to achieve lower rates of TVR compared with conventional BMS.

Methods: Consecutive STEMI cases admitted within 12 h of symptom onset and undergoing primary angioplasty and bare metal stent implantation 1 January 2002 and 31 December 2008 were identified. Primary outcomes were rates of clinically-driven TVR at six months as well as occurrence of major adverse cardiovascular events (MACE) either of all-cause death, repeat myocardial infarction or TVR at six months.

Results: 1030 cases with 1175 lesions (84% males) and median age of 58 years underwent primary PCI for STEMI in our registry. Overall procedural success rate was 98%. Stainless steel stents were inserted in 65% of the culprit lesions (stainless steel, n = 766 versus cobalt chromium, n = 264). Primary outcomes of TVR (3.5% in the stainless steel group and 3.4% in the cobalt chromium group, P = 0.93) and MACE (8.4% in the stainless steel group and 5.3% in the cobalt chromium group, P = 0.11) after six months were no different between the two groups. However, there were more deaths at 30 days in the stainless steel group compared to the cobalt chromium group (3.5% versus 0.4%, HR 4.04 (1.03–3.88), P = 0.04).

Conclusion: Both cobalt-chromium and stainless steel coronary stents were associated with similar and low risk of clinically-driven TVR.     

Is off-pump coronary artery bypass grafting superior to drug-eluting stents for the treatment of coronary artery disease? A meta-analysis of randomized and nonrandomized studies

Background

As drug-eluting stent (DES) has almost overcome the disadvantage of frequent restenosis, off-pump coronary artery bypass grafting (OPCAB) has been introduced to avoid complications of cardiopulmonary bypass. However, which approach may promise better outcomes for patients with coronary artery disease remains controversial.

Methods

Three databases were searched. The outcomes of interest were major adverse cardiac and cerebrovascular events (MACCE), all-cause death, target vessel revascularization (TVR), repeat revascularization (RRV), myocardial infarction (MI), and cerebrovascular events (CVE). The relative risk (RR) was calculated as the summary statistic.

Results

11,452 patients from 22 studies were included, of which 4949 patients underwent OPCAB and 6503 patients received DES. The cumulative rates of MACCE (RR [95% CI] = 0.43 [0.34, 0.54], P < 0.00001), all-cause death (RR [95% CI] = 0.56 [0.33, 0.96], P = 0.03), TVR (RR [95% CI] = 0.33 [0.21, 0.53], P < 0.00001), RRV (RR [95% CI] = 0.22 [0.11, 0.42], P < 0.00001) and MI (RR [95% CI] = 0.13 [0.05, 0.29], P < 0.00001) at 3 years were all lower in OPCAB group. The incidences of in-hospital death (RR [95% CI] = 1.31 [0.81, 2.13], P = 0.27) and MI (RR [95% CI] = 1.03 [0.60, 1.78], P = 0.92) were not different between groups, but the rate of in-hospital CVE was lower (RR [95% CI] = 2.6355 [1.0033, 6.9228], P = 0.05) in DES group.

Conclusions

OPCAB presents better long-term outcomes of MACCE, all-cause mortality, TVR, RRV and MI but uncertain outcome of postoperative CVE without influencing the incidences of in-hospital death and MI.     

Multivessel Versus Culprit-Vessel Percutaneous Coronary Intervention in Cardiogenic Shock

ObjectivesThis study sought to compare outcomes of patients enrolled in the NCSI (National Cardiogenic Shock Initiative) trial who were treated using a revascularization strategy of percutaneous coronary intervention (PCI) of multivessel PCI (MV-PCI) versus culprit-vessel PCI (CV-PCI).BackgroundIn patients with multivessel disease who present with acute myocardial infarction and cardiogenic shock (AMICS), intervening on the nonculprit vessel is controversial. There are conflicting published reports and lack of evidence, particularly in patients treated with early mechanical circulatory support (MCS).MethodsFrom July 2016 to December 2019, patients who presented with AMICS to 57 participating hospitals were included in this analysis. All patients were treated using a standard shock protocol emphasizing early MCS, revascularization, and invasive hemodynamic monitoring. Patients with multivessel coronary artery disease (MVCAD) were analyzed according to whether CV-PCI or MV-PCI was undertaken during the index procedure.ResultsOf 198 patients with MVCAD, 126 underwent MV-PCI (64%) and 72 underwent CV-PCI (36%). Demographics between the cohorts were similar with respect to age, sex, history of diabetes, prior PCI or coronary artery bypass grafting, and prior history of myocardial infarction. Patients who underwent MV-PCI had a trend toward more severe impairment of cardiac output and worse lactate clearance on presentation, and cardiac performance was significantly worse at 12 h. However, 24 h from PCI, the hemometabolic derangements were similar. Survival and rates of acute kidney injury were not significantly different between groups (69.8% MV-PCI vs. 65.3% CV-PCI; p = 0.51; and 29.9% vs. 34.2%; p = 0.64, respectively).ConclusionsIn patients with MVCAD presenting with AMICS treated with early MCS, revascularization of nonculprit lesions was associated with similar hospital survival and acute kidney injury when compared with culprit-only PCI. Selective nonculprit PCI can be safety performed in AMICS in patients supported with mechanical circulatory support.     

The efficacy of everolimus-eluting stent implantation in patients with ST-segment elevation myocardial infarction: outcomes of 2-year clinical follow-up

First-generation drug-eluting stents (DES) demonstrated delay in vascular healing and increase in incidence of late and very late stent thrombosis compared with bare-metal stents (BMS). Second-generation DES, however, have shown a reduction of late and very late stent thrombosis compared with first-generation DES. Thus, we decided to evaluate whether the second-generation everolimus-eluting stent (EES) has an advantage over BMS in Japanese patients with ST-segment elevation myocardial infarction (STEMI). This study was conducted in two centers, retrospective, non-randomized and observational design in patients with STEMI. Three-hundred eighty patients were randomly selected to receive EES (198 patients) or cobalt-chromium BMS (182 patients). The primary endpoints were cardiac death, recurrent myocardial infarction (MI), target lesion revascularization (TLR), target vessel revascularization (TVR), and stent thrombosis (ST). At 2 years, the rates of TLR, TVR, and recurrent MI were significantly lower in the EES group than in the BMS group (TLR 1.5 vs. 8.3 %, p < 0.05; TVR 2.5 vs. 9.4 %, p < 0.05; recurrent MI 1.0 vs. 4.1 %, p < 0.05), and the rate of ST was also significantly lower in the EES group than in the BMS group (0.5 vs. 4.3 %, p < 0.05). Thus, major adverse cardiac events defined at the composite cardiac death, MI, TLR, TVR, or ST were significantly lower in EES group than in BMS group (3.0 vs. 9.9 %, p = 0.008). The rate of cardiac death, however, did not differ between both groups. In STEMI patients, EES may be associated with improved outcomes—specifically, a significant reduction in TVR, ST, and recurrent MI compared to BMS throughout 2 years.     

Sirolimus-eluting versus paclitaxel-eluting stent in primary angioplasty: a pooled patient-level meta-analysis of randomized trials

Large interests have been focused on the role of drug-eluting stents in the setting of ST-segment elevation myocardial infarction (STEMI) and concerns have emerged regarding an higher risk of stent thrombosis. Aim of the current study was to perform a meta-analysis using individual patient data to evaluate the long-term safety and effectiveness of sirolimus-eluting stent (SES) as compared to paclitaxel-eluting stent (PES) in patients undergoing primary percutaneous coronary intervention (PCI) for STEMI. The literature was scanned by formal searches of electronic databases (MEDLINE and CENTRAL). We examined all completed randomized trials of SES versus PES for STEMI. No language restriction was applied. Primary study endpoint was the occurrence of major adverse cardiac events (MACE). Secondary endpoints were the occurrence of death, reinfarction, stent thrombosis, target-vessel revascularization (TVR). Individual patient data were obtained from 4 out of 5 trials identified, including a total of 1,000 patients, 504 (50.4 %) randomized to SES and 496 (49.6 %) randomized to PES. At long-term follow-up (1,021 [372–1,351] days), no difference was observed between SES and PES in terms of TVR (10 vs 11.6 %, HR [95 % CI 0.73 [0.45–1.16], p = 0.18, p het = 0.92]) (primary endpoint) or death (9.4 vs 10.4 %, HR [95 % CI 0.95 [0.58–1.54], p = 0.82, p het = 0.89]), reinfarction (8.2 vs 10.4 %, HR [95 % CI 0.91 [0.53–1.57], p = 0.73, p het = 0.83]), stent thrombosis (7.4 vs 4.6 %, HR [95 % CI 1.04 [0.55–2.05], p = 0.92, p het = 0.65]), and MACE (10 vs 13.6 %, HR [95 % CI 0.86 [0.63–1.18], p = 0.36, p het = 0.84]) (secondary endpoints). The present pooled patient-level meta-analysis demonstrates that, among STEMI patients undergoing primary PCI, SES and PES are associated with a similar outcome at long-term follow-up, in terms of death, reinfarction, stent thrombosis, TVR and MACE.     

Different Statin Effects of ST-elevation Versus Non-ST-Elevation Acute Myocardial Infarction After Stent Implantation

BackgroundIntensive statin therapy reduces cardiovascular events in acute coronary syndrome. The data concerning the long-term clinical impacts of statin therapy between ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) after drug-eluting stent implantation are limited. We compared the 2-year clinical outcomes between these 2 groups after statin therapy.Materials and MethodsA total of 30,616 Korean patients with acute myocardial infarction (AMI) were enrolled. Among them, 13,686 patients were classified as group A (STEMI statin user), 3,824 patients were as group B (STEMI statin nonuser), 10,398 patients were as group C (NSTEMI statin user), and 2,708 patients were as group D (NSTEMI statin nonuser). The major clinical endpoint was the occurrence of major adverse cardiac events (MACE) defined as all-cause death, recurrent myocardial infarction (re-MI), and any repeat revascularization during a 2-year follow-up period.ResultsAfter adjustment, the cumulative risks of MACE (adjusted hazard ratio [aHR] = 1.112 [1.002-1.235]; P = 0.047), all-cause death (aHR = 1.271 [1.054-1.532]; P = 0.012), and target vessel revascularization (TVR, aHR = 1.262 [1.049-1.518]; P = 0.014) in group C were significantly higher than group A. The cumulative risks of MACE, all-cause death, and cardiac death of the statin nonuser group (groups B and D) were significantly higher compared with statin user group (groups A and C).ConclusionsStatin therapy was more effective in reducing the cumulative risks of MACE, all-cause death, and TVR in the STEMI group than NSTEMI group in Korean patients with AMI after successful drug-eluting stent implantation.     

Clinical impact of simultaneous complete revascularization vs. culprit only primary angioplasty in patients with st-elevation myocardial infarction and multivessel disease: a meta-analysis

Primary Percutaneous Intervention (PCI) is the treatment of choice for acute ST-elevation myocardial infarction (STEMI). Nearly half of STEMI patients have multivessel (MV) disease that has been associated with worse survival. However, current guidelines recommend to treat only the culprit artery (COR) during the acute procedure. Thus, the aim of the current study was to perform a meta-analysis of trials comparing MV PCI vs. COR for STEMI patients with MV disease. Medline/CENTRAL and Web were searched for comparative studies (both randomized and non randomized trials) about MV PCI vs. COR for STEMI patients reporting mortality, re-PCI and re-MI data. Primary endpoint was 30-day mortality. The meta-analysis included 10 studies (2 randomized and 8 registries; N = 31224). As compared with COR, MV PCI significantly reduced long term rate of re-PCI (OR [95% CI] = 0.47 [0.28–0.78], P = 0.003) without increasing 30-day mortality (OR [95% CI] = 1.30 [0.79–2.12], P = 0.31) and long term re-MI (OR [95% CI] = 0.94 [0.43–2.06], P = 0.88). This meta-analysis showed safety and efficacy of MV PCI approach as compared with COR, with a significant reduction in rate of revascularizations, but no advantages in death and re-MI.