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Published on: January 18, 2018
Acute multivessel revascularization improves 1-year outcome in ST-elevation myocardial infarction: a nationwide study
Raban Jeger1, Milosz Jaguszewski2, Brahmajee N Nallamothu3
1Cardiology, University Hospital, Basel, Switzerland.
Insights
Immediate complete revascularization in ST-segment elevation myocardial infarction (STEMI) with multi-vessel disease (MVD) reduced major adverse cardiovascular events (MACCE) but not mortality. Drug-eluting stents further improved outcomes in this patient group.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Research
Background:
- The optimal percutaneous coronary intervention (PCI) strategy for ST-segment elevation myocardial infarction (STEMI) in patients with multi-vessel disease (MVD) remains unclear.
- Comparing multi-vessel PCI (MV-PCI) versus infarct-related artery PCI (IRA-PCI) is crucial for treatment optimization.
Purpose of the Study:
- To compare the effectiveness of MV-PCI versus IRA-PCI in STEMI patients with MVD.
- To evaluate the impact of different stent types on clinical outcomes in this population.
Main Methods:
- Analysis of 8330 STEMI patients from the AMIS Plus registry (2005-2012).
- 1909 patients had MVD, with 442 undergoing MV-PCI and 1467 undergoing IRA-PCI.
- Primary endpoint: all-cause death. Secondary endpoint: major adverse cardiovascular and cerebrovascular events (MACCE) at median 378-day follow-up.
Main Results:
- MV-PCI was associated with significantly lower MACCE (15.6% vs. 20.0%, p=0.038) compared to IRA-PCI, driven by reduced re-hospitalization and re-intervention.
- All-cause mortality was similar between MV-PCI and IRA-PCI groups (2.7%).
- Patients receiving MV-PCI with drug-eluting stents showed lower mortality (2.1% vs. 7.4%) and MACCE (14.1% vs. 25.9%) compared to bare metal stents (BMS).
- MV-PCI was an independent predictor for reduced 1-year MACCE (OR 0.69, p=0.017).
Conclusions:
- Immediate complete revascularization (MV-PCI) may benefit STEMI patients with MVD regarding MACCE, particularly when using drug-eluting stents.
- Mortality benefit was not observed with MV-PCI in this real-world cohort.
- Further validation in randomized controlled trials is warranted to confirm these findings.
Background:
The optimal strategy for percutaneous coronary intervention (PCI) of ST-segment elevation myocardial infarction (STEMI) in multi-vessel disease (MVD), i.e., multi-vessel PCI (MV-PCI) vs. PCI of the infarct-related artery only (IRA-PCI), still remains unknown.
Methods:
Patients of the AMIS Plus registry admitted with an acute coronary syndrome were contacted after a median of 378 days (interquartile range 371-409). The primary end-point was all-cause death. The secondary end-point included all major adverse cardiovascular and cerebrovascular events (MACCE) including death, re-infarction, re-hospitalization for cardiac causes, any cardiac re-intervention, and stroke.
Results:
Between 2005 and 2012, 8330 STEMI patients were identified, of whom 1909 (24%) had MVD. Of these, 442 (23%) received MV-PCI and 1467 (77%) IRA-PCI. While all-cause mortality was similar in both groups (2.7% both, p>0.99), MACCE was significantly lower after MV-PCI vs. IRA-PCI (15.6% vs. 20.0%, p=0.038), mainly driven by lower rates of cardiac re-hospitalization and cardiac re-intervention. Patients undergoing MV-PCI with drug-eluting stents had lower rates of all-cause mortality (2.1% vs. 7.4%, p=0.026) and MACCE (14.1% vs. 25.9%, p=0.042) compared with those receiving bare metal stents (BMS). In multivariate analysis, MV-PCI (odds ratio, OR 0.69, 95% CI 0.51-0.93, p=0.017) and comorbidities (Charlson index ≥ 2; OR 1.42, 95% CI 1.05-1.92, p=0.025) were independent predictors for 1-year MACCE.
Conclusion:
In an unselected nationwide real-world cohort, an approach using immediate complete revascularization may be beneficial in STEMI patients with MVD regarding MACCE, specifically when drug-eluting stents are used, but not regarding mortality. This has to be tested in a randomized controlled trial.
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