Managing the Intricacies of Coronary Revascularization: A Close Look at the Complete Versus Culprit-Only Approach and
Mahmoud El Hajj1, Bana Hadid2, Akiva Rosenzveig3
1From the Department of Internal Medicine, Montefiore St. Luke's Cornwall Hospital, Newburgh, NY.
Insights
For elderly patients with acute myocardial infarction (MI), complete revascularization may be more beneficial than culprit-only treatment, even in frail individuals. This finding challenges traditional conservative approaches for this vulnerable population.
Area of Science:
- Cardiology
- Geriatrics
- Interventional Cardiology
Background:
- Coronary heart disease (CHD) is a leading cause of mortality in the US, with 805,000 annual myocardial infarctions (MI).
- Frailty, a decline in function with aging, is associated with poor outcomes in cardiovascular disease.
- Current practice often favors conservative medical management for frail patients with acute coronary syndrome (ACS).
Purpose of the Study:
- To review guidelines and procedures for culprit lesion identification in ACS.
- To discuss the concept of complete versus culprit-only/incomplete coronary revascularization.
- To analyze recent trials, particularly the Functional Assessment in Elderly MI Patients with Multivessel Disease trial, focusing on frail patients.
Main Methods:
- Review of clinical practice guidelines for ACS management.
- Discussion of diagnostic procedures: electrocardiogram (ECG), coronary angiography, intravascular ultrasound (IVUS), fractional flow reserve (FFR), and instantaneous fractional flow reserve (iFR).
- Analysis of data from the Functional Assessment in Elderly MI Patients with Multivessel Disease trial.
Main Results:
- The Functional Assessment in Elderly MI Patients with Multivessel Disease trial suggests complete revascularization may be superior to incomplete or culprit-only revascularization in elderly patients (≥75 years) with acute MI.
- This challenges the conventional approach of conservative therapy for frail patients with ACS.
Conclusions:
- Elderly patients with acute MI, including those who are frail, may benefit from a complete revascularization strategy.
- Further consideration of invasive complete revascularization is warranted in this specific patient cohort.
- This review highlights evolving treatment paradigms in managing acute coronary syndrome in elderly and frail populations.
Abstract:
Coronary heart disease is the leading cause of mortality in the United States, and data indicates that 805,000 Americans will face a new or recurrent myocardial infarction (MI) attack every year. Frailty, a conceptual syndrome categorized by a functional decline that occurs with aging, has been linked to adverse health outcomes in cardiovascular disease and all cardiac-related procedures in general. It is therefore reasonable to deliberate that more conservative medical therapy or medical management should be considered in the frail population when managing acute coronary syndrome. This course of action has, in fact, been documented in clinical practice. However, the recent Functional Assessment in Elderly MI Patients with Multivessel Disease trial, in which all subjects were 75 years of age or above, indicated that the more invasive complete revascularization approach may be favorable over incomplete or culprit-only revascularization in patients with acute MI. In this review, we will discuss coronary heart disease and review guidelines and procedures for culprit lesion identification, including electrocardiogram procedures, coronary angiography, intravascular ultrasound, fractional flow reserve, and instantaneous fractional flow reserve. We then discuss the concept of complete vs culprit-only/incomplete coronary revascularization and staging. Following this, we will delve into recent trials discussing complete vs culprit-only revascularization, emphasizing the insights gleaned from this latest trial within this special frailty cohort which warrants special consideration.
