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Timing of Complete Revascularization with Multivessel PCI for Myocardial Infarction.
Barbara E Stähli1, Ferdinando Varbella1, Axel Linke1
1From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom.
Immediate multivessel percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) patients with multivessel disease is noninferior to staged PCI. This approach significantly reduces major adverse events within one year.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Optimal timing for complete revascularization in STEMI patients with multivessel coronary artery disease is not well-defined.
- Current guidelines lack definitive recommendations for non-culprit lesion treatment in this patient population.
Purpose of the Study:
- To compare the efficacy and safety of immediate versus staged multivessel PCI in hemodynamically stable STEMI patients with multivessel coronary artery disease.
- To determine if immediate complete revascularization is noninferior to a staged approach for key clinical outcomes.
Main Methods:
- An international, open-label, randomized, noninferiority trial involving 37 European sites.
- Patients with STEMI and multivessel coronary artery disease were randomized to either immediate multivessel PCI or culprit lesion PCI followed by staged multivessel PCI within 19-45 days.
- The primary endpoint was a composite of all-cause death, nonfatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or heart failure hospitalization at 1 year.
Main Results:
- A total of 840 patients were randomized (418 immediate, 422 staged).
- The primary endpoint occurred in 8.5% of the immediate group versus 16.3% in the staged group (Risk Ratio 0.52; P<0.001 for noninferiority and superiority).
- Specific reductions were observed in nonfatal myocardial infarction and unplanned revascularization in the immediate group. Risks for death, stroke, and heart failure hospitalization were similar between groups.
Conclusions:
- Immediate multivessel PCI is a safe and effective strategy for hemodynamically stable STEMI patients with multivessel coronary artery disease.
- The immediate approach demonstrated noninferiority to staged PCI, with a significant reduction in major adverse cardiovascular events at one year.
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