Multivessel percutaneous coronary intervention in patients with multivessel disease and acute myocardial infarction

Corpus, Roberto A.; House, John A.; Marso, Steven P.; Grantham, J. Aaron; Huber, Kenneth C.; Laster, Steven B.; Johnson, Warren L.; Daniels, William C.; Barth, Charles W.; Giorgi, Lee V.; Rutherford, Barry D.

doi:10.1016/j.ahj.2004.03.051

Cited by 198 publications

(154 citation statements)

References 24 publications

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“…63 Short-term PCI of non-infarct-related artery vessels during MI is associated with more complications than delayed non-infarct-related artery treatment. 64 In clinical practice, as in the SHOCK trial, 59 multivessel PCI is performed in approximately one fourth of patients with CS undergoing PCI. This translates into multivessel PCI in just over one third of those with multivessel disease.…”

Section: Multivessel Diseasementioning

confidence: 99%

Cardiogenic Shock

2008

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ardiogenic shock (CS) occurs in Ϸ5% to 8% of patients hospitalized with ST-elevation myocardial infarction (STEMI). Recent research has suggested that the peripheral vasculature and neurohormonal and cytokine systems play a role in the pathogenesis and persistence of CS. Early revascularization for CS improves survival substantially. New mechanical approaches to treatment are available, and clinical trials are feasible even in this high-risk population. Most importantly, hospital survivors have an excellent chance for long-term survival with good quality of life. This review will outline the causes, pathophysiology, and treatment of CS with a focus on CS complicating myocardial infarction (MI.) The case will be made for viewing CS as a serious disorder with a high early death rate, but one that is treatable and that, if approached aggressively, can result in full recovery. The diagnosis is usually made with the help of pulmonary artery (PA) catheterization; however, Doppler echocardiography may also be used to confirm elevation of LV filling pressures. 1 Hypoperfusion may be manifest clinically by cool extremities, decreased urine output, and/or alteration in mental status. Hemodynamic abnormalities form a spectrum that ranges from mild hypoperfusion to profound shock, and the short-term outcome is directly related to the severity of hemodynamic derangement. MI with LV failure remains the most common cause of CS. It is critical to exclude complicating factors that may cause shock in MI patients. Chief among these are the mechanical complications: ventricular septal rupture, contained free wall rupture, and papillary muscle rupture. Mechanical complications must be strongly suspected in patients with CS complicating nonanterior MI, particularly a first MI. Echocardiography is the technique of choice to rule out these entities and should be performed early unless the diagnosis is extensive anterior MI and the patient is undergoing prompt percutaneous coronary intervention (PCI). In addition, the detection of valvular disease before angiography may alter the revascularization approach. Diagnosis and CausesHemorrhage, infection, and/or bowel ischemia may contribute to shock in the setting of MI. As with mechanical complications, a high index of suspicion is required to make these diagnoses in MI patients, and survival may depend on timely recognition and treatment.Any cause of acute, severe LV or RV dysfunction may lead to CS. Acute myopericarditis, tako-tsubo cardiomyopathy, and hypertrophic cardiomyopathy may all present with ST elevation, release of cardiac markers, and shock in the absence of significant coronary artery disease. Stress-induced cardiomyopathy, also known as apical ballooning or takotsubo cardiomyopathy, is a syndrome of acute LV dysfunction after emotional or respiratory distress that leads to CS in 4.2% of cases. 2 Acute valvular regurgitation, typically caused by endocarditis or chordal rupture due to trauma or degenerative disease, may also cause CS. Aortic dissection may lead to CS via acute,...

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Section: Multivessel Diseasementioning

confidence: 99%

Cardiogenic Shock

2008

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“…MVD occurs in 28-67% of patients with STEMI and is an independent predictor (IP) of short-to medium-term prognosis, as summarised in Table 1. [5][6][7][8][9][10] The presence of a chronic total occlusion in the non-IRA confers a particularly poor prognosis and was an IP of mortality and reduction in LV ejection fraction (LVEF) post STEMI after correcting for baseline risk profile and cardiogenic shock. …”

Section: Chapter 1 Introductionmentioning

confidence: 99%

The randomised Complete versus Lesion-only PRimary percutaneous coronary Intervention Trial: Cardiovascular Magnetic Resonance imaging substudy (CvLPRIT-CMR)

et al. 2016

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BackgroundComplete revascularisation in patients with multivessel disease who are treated with primary percutaneous coronary intervention (PPCI) may improve outcomes compared with an infarct-related artery (IRA)-only strategy. However, non-IRA percutaneous coronary intervention (PCI) may result in additional myocardial infarction (MI).ObjectivesTo determine whether or not in-hospital complete revascularisation was associated with increased total infarct size (IS) in patients participating in the Complete versus Lesion-only PPCI trial (CvLPRIT). Secondary objectives were to assess whether or not myocardial salvage index, myocardial ischaemia and final IS at follow-up were different with a complete revascularisation versus an IRA-only strategy.DesignMulticentre, prospective, randomised, controlled and open-label trial with blinded end-point analysis.SettingSeven PPCI centres in England, UK.ParticipantsST-segment elevation MI (STEMI) patients with multivessel disease (angiographic stenosis > 70% in one view or > 50% in orthogonal views) presenting within 12 hours of symptom onset and treated with the PPCI. Coronary artery bypass surgery, cardiogenic shock and contraindications to cardiovascular magnetic resonance (CMR; substudy only) imaging were exclusions.InterventionsPatients were randomised to either complete in-hospital revascularisation or an IRA-only strategy.Main outcome measuresThe primary outcome was IS as measured by CMR undertaken at 48–72 hours post PPCI. Secondary outcome measures included microvascular obstruction, myocardial salvage index, left ventricular volumes and ejection fraction and final IS on the acute and follow-up CMR carried out at 9 months post STEMI.ResultsPatients were recruited from May 2011 until May 2013 and followed up for 12 months. Of 296 patients randomised in the main CvLPRIT, 205 consented to participate in the CMR substudy and 203 had analysable images for the primary end point. Patients in the IRA-only group (n = 105) were well matched to those in the complete revascularisation group (n = 98) for all baseline characteristics {mean age 64.1 years [standard deviation (SD) 10.8 years] vs. 63.1 years (SD 11.3 years); male sex 89% vs. 79%, respectively}. Total IS was not significantly different in the IRA-only and complete revascularisation groups {median 13.5% [interquartile range (IQR) 6.2–21.9%] of left ventricular (LV) mass vs. median 12.6% (IQR 7.2–22.6%) LV mass, respectively; 95% confidence interval –4.09% to 31.17%;p = 0.57}. Myocardial salvage index was also not significantly different in the IRA-only and complete revascularisation groups [median 58.5% (IQR 32.8–74.9%) vs. median 60.5% (IQR 40.6–81.9%), respectively;p = 0.14]. The prevalence of non-IRA MI on acute CMR was higher in the complete revascularisation group than in the IRA-only group (22/98 vs. 11/105, respectively;p = 0.02). There was no difference in total IS, ischaemic burden or LV volumes between treatment groups at follow-up CMR.LimitationsThe CMR substudy population may not be a true representation of the overall study population. The optimal timing of CMR to measure IS post PPCI is uncertain. Myocardial salvage was assessable in only 70% of patients.ConclusionsMultivessel PCI, compared with an IRA-only revascularisation, in the setting of STEMI led to a small increase in CMR imaging-detected non-IRA MI, but total IS was not increased.Future workLarger studies are required to (1) confirm that death and MI are reduced by a complete revascularisation strategy; (2) assess whether or not functional assessment of non-IRA lesions results in similar outcomes to a pragmatic angiographic-based revascularisation strategy; and (3) assess the timing of in-hospital versus staged outpatient complete revascularisation.Trial registrationCurrent Controlled Trials ISRCTN70913605.FundingThis project was funded by the Efficacy and Mechanism Evaluation (EME) programme, a Medical Research Council and National Institute for Health Research (NIHR) partnership. The main CvLPRIT was funded by the British Heart Foundation (SP/10/001) with support from the NIHR Comprehensive Local Research Networks.

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“…These guidelines were based on the hypothesis that MPS may increase the risk of MACE and not reasonable in financial effects compare with one-vessel PCI. Several trials suggest that one-vessel PCI strategy avoiding the longer procedures and its complications with ischemia in non-infarcted myocardial regions, decrease of contrast medium volume and risk of contrast induced nephropathy [15,18].…”

Section: Discussionmentioning

confidence: 99%

“…According to published trials, one-year incidence of adverse cardiovascular events (MACE) in STEMI MVCAD patients of general cohort with bare metal stents and DES ranged from 23.9 to 28%, re-MI from 1.6 to 8.8%, death from 3.3 to 6.3%, ST from 1.8 to 4.3% [12,15,18]. In presented randomized trial oneyear MACE, re-MI, death and ST occurred in 5.1%, 5.1%, 2.9% and 4.4% of patients, respectively.…”

Section: Discussionmentioning

confidence: 99%

“…Earlier results of trials comparing MPS and CO approaches were controversial [12][13][14][15][16][17][18][19], probably due to the heterogeneity of patient samples, variable endpoints, distinct inclusion criteria and different study protocols. European and American Cardiology Societies for 2010-2013 [1][2][3] recommended limiting PPCI to the vessel with a culprit stenosis with the exception of cardiogenic shock and persistent ischaemia after PCI.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Coronary air embolism during coronary angiography: reminder of a potentially lethal but avoidable complication

Mahajan¹,

Asotra²,

Negi³

et al. 2017

Interventional-Cardiology

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Background: Preventive multivessel percutaneous coronary interventions (PCI) (in primary and staged revascularization) with second generation drug eluting stents (DES) in patients with STelevation myocardial infarction (STEMI) is unresolved and controversial issue of contemporary interventional cardiology. Twelve-month results of our randomized trial (NCT01781715) presented. Methods and findings: One-year outcomes of 136 consecutive patients with STEMI and multivessel coronary artery disease (MVCAD) (SYNTAX Score 18.9±7.7 points) undergoing primary PCI with zotarolimus-eluting stents (Resolute Integrity™ Stent, Medtronic) were evaluated. The patients were randomized into two groups of preventive multivessel stenting: Multivessel primary stenting (MPS primary, n=67) (the infarct-related artery (IRA) and non-IRA stenting during one PCI) and multivessel stenting in staged revascularisation (MSS, n=69) (the IRA only stenting during the primary PCI and non-IRA stenting during the same hospital period (10.1±5.1 days between PCIs). Over the 12-month observation there were no differences in adverse cardiovascular events among MPS and MSS group. Fatality outcomes in both groups were not exceeded 3%. No MI and re-PCI survival was 62 (92.5%) patients in MPS group and 67 (97.1%) in MSS group p>0.05). In general study population (n=136) MACE, re-MI, death and stent thrombosis obtained in 5.1%, 5.1%, 2.9% and 4.4% of patients, respectively. Conclusions: The use of similar latest generation DES and preventive approach (MPS and MSS with 10.1±5.1 days between procedures) used in index hospitalization period made it possible to obtain satisfactory results of revascularization compared to most similar randomized trials.

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Multivessel percutaneous coronary intervention in patients with multivessel disease and acute myocardial infarction

Cited by 198 publications

References 24 publications

Cardiogenic Shock

Cardiogenic Shock

The randomised Complete versus Lesion-only PRimary percutaneous coronary Intervention Trial: Cardiovascular Magnetic Resonance imaging substudy (CvLPRIT-CMR)

Coronary air embolism during coronary angiography: reminder of a potentially lethal but avoidable complication

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