Non-infarct related artery revascularization in ST-segment elevation myocardial infarction patients with multivessel
Asim N Cheema1, Shamir R Mehta, Subodh Verma
1aTerrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto bHamilton Health Sciences, General Division, Hamilton cDivision of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
Insights
Revascularization of non-infarct-related arteries in ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease (MVD) improves cardiovascular outcomes. This strategy is now recommended for selected stable patients, with ongoing studies to refine its role.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Multivessel disease (MVD) is prevalent in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI).
- MVD is linked to increased risks of future cardiovascular events and mortality.
- Current management of non-infarct-related artery (IRA) stenosis in STEMI requires further clarification.
Purpose of the Study:
- To review the pathophysiology of MVD in STEMI and its impact on prognosis.
- To examine evidence guiding the management of non-IRA stenosis in STEMI patients.
- To identify knowledge gaps for future research on MVD in STEMI.
Main Methods:
- Review of recent randomized trials and observational data.
- Analysis of pooled results from small randomized trials.
- Examination of current clinical guidelines and recommendations.
Main Results:
- Pooled data suggest improved cardiovascular outcomes, including mortality and repeat revascularization, with non-IRA stenosis revascularization versus medical management alone.
- No significant increase in bleeding, contrast-induced nephropathy, or stroke was observed.
- Recent data support a Class IIb recommendation for considering non-IRA revascularization in selected stable STEMI patients.
Conclusions:
- Non-IRA revascularization may be considered in hemodynamically stable STEMI patients with MVD.
- This can be performed either during primary PCI or as a staged procedure.
- Ongoing studies like COMPLETE and CULPRIT-SHOCK will further define the optimal role and timing of non-IRA revascularization.
Purpose Of Review:
Multivessel disease (MVD) is common in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) and is associated with significant risk of future cardiovascular (CV) events including short and longer-term mortality. In this review, we examine the pathophysiologic construct contributing to adverse prognosis of MVD in STEMI, relevant available evidence that currently guides the management of the noninfarct-related artery (IRA) stenosis and define the remaining knowledge gaps for future studies.
Recent Findings:
Results of recent small sized randomized trials, when pooled, suggest improvement in CV outcomes including CV mortality and repeat revascularization with revascularization of the non-IRA stenosis compared with medical management alone. In addition, there does not appear to be an increase in bleeding, contrast-induced nephropathy or stroke, as suggested by earlier observational data.
Summary:
These recent data have led to a Class IIb recommendation in the American College of Cardiology/American Heart Association guidelines stating that non-IRA revascularization may be considered in selected patients with STEMI and MVD who are hemodynamically stable, either at the time of primary PCI or as a planned staged procedure. The ongoing COMPLETE and CULPRIT-SHOCK studies will provide additional data to further inform the role of non-IRA revascularization and its timing in the management of these patients.
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