Multivessel coronary disease diagnosed at the time of primary PCI for STEMI: complete revascularisation versus conservative strategy. Prague-13 trial

Czech version

Authors: O. Hlinomaz ¹; L. Groch ¹; K. Poloková ¹; F. Lehar ¹; T. Vekov ²; R. Petkov ²; M. Stojnev ²; M. Gřiva ³; J. Sitár ¹; M. Rezek ¹; M. Novák ¹; J. Seménka ¹; N. Penkov ²
Authors‘ workplace: I. interní kardioangiologická klinika LF MU a FN u sv. Anny v Brně ¹; Bulharský kardiologický institut, Sofie, Bulharsko ²; Krajská nemocnice T. Bati, Zlín ³
Published in: Kardiol Rev Int Med 2015, 17(3): 214-220
Category: Cardiology Review

Overview

Primary percutaneous coronary intervention (PPCI) in the occlusion or significant stenosis of an infarct (culprit) artery is a method of choice in the treatment of acute myocardial infarction with ST segment elevation (STEMI). The purpose of this trial was to identify the optimal management of patients with STEMI treated by PPCI who have at least one significant (≥ 70%) stenosis of a non-culprit coronary artery. Between 2009 and 2013, 214 patients with STEMI and multivessel coronary disease, successfully treated with infarct-related artery PPCI, were enrolled into the trial in six centres. One hundred and eight patients were randomly assigned to a non-PCI group and 106 to a staged PCI group. Patients with limiting angina pectoris present for more than 1 month prior to STEMI were excluded from the trial, among others. There were no significant differences in the baseline characteristics between both groups. The primary endpoint of the study was the incidence of the combined endpoint of all-cause mortality, nonfatal myocardial infarction and stroke during the follow-up in the group of patients treated with staged PCI in comparison with patients treated conservatively. An intention-to-treat analysis was used. Patients were followed for 38 months (median). The composite primary endpoint appeared in 15 (13.9%) patients in the non-PCI group and 17 (16.0%) in the PCI group; the hazard ratio in staged PCI group being 1.35; 95% CI 0.66–2.74; p=0.407. The hazard ratio for all-cause mortality was 0.91 (95% CI 0.30–2.70) and for nonfatal myocardial infarction 1.71 (95% CI 0.66–4.41) in the staged PCI group. Nineteen (17.6%) patients from the non-PCI group had a PCI of non-culprit coronary artery during the follow-up due to progression of angina symptoms or acute myocardial infarction. Only 13 (6.1%) patients had a non-culprit artery stenosis of ≥95% and the average non-culprit coronary artery stenosis diameter was 80%. This trial found no difference (not even a trend) favouring staged multivessel PCI over culprit-only PPCI in STEMI patients. Larger trials are needed to clarify the revascularisation strategy in STEMI patients with multivessel disease.

Keywords:
primary PCI – acute myocardial infarction – multivessel coronary disease – revascularisation

Sources

1. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003; 361: 13– 20.

2. O’Gara PT, Kushna FG, Ascheim DD et al. 2013 ACCF/ AHA Guideline for the management of 1st‑ elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines. Circulation 2013; 127: 529– 555. doi: 10.1161/ CIR.0b013e3182742c84.

3. Steg G, James SK, Atar D et al. The Task Force on the management of ST‑segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST‑segment elevation. Eur Heart J 2012; 33: 2569– 2619. doi: 10.1093/ eurheartj/ ehs215.

4. Windecker S, Kolh P, Alfonso F et al. 2014 ESC/ EACTS Guidelines on myocardial revascularization. The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio‑ Thoracic Surgery (EACTS). Eur Heart J 2014; 35: 3541– 3619. doi: 10.1093/ eurheartj/ ehu278.

5. Patel MR, Dehmer GJ, Hirshfeld JW et al. ACCF// SCAI/ STS/ AATS/ AHA/ ASNC 2009 Appropriateness Criteria for Coronary Revascularization: A Report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, and the American Society of Nuclear Cardiology: Endorsed by the American Society of Echocardiography, the Heart Failure Society of America, and the Society of Cardiovascular Computed Tomography. Circulation 2009; 119: 1330– 1352. doi: 10.1161/ CIRCULATIONAHA.108.191768.

6. Bangalore S, Faxon DP. Coronary intervention in patients with acute coronary syndrome: does every culprit lesion require revascularization? Curr Cardiol Rep 2010; 12: 330– 337. doi: 10.1007/ s11886‑ 010‑ 0115‑ 8.

7. Di Mario C, Mara S, Flavio A et al. Single vs. multivessel treatment during primary angioplasty: results of the multicentre randomised HEpacoat for cuLPrit or multivessel stenting for Acute Myocardial Infarction (HELP AMI) Study. Int J Cardiovasc Intervent 2004; 6: 128– 133.

8. Qarawani D, Nahir M, Abboud M et al. Culprit only versus complete revascularization during primary PCI. Int J Cardiol 2008; 123: 288– 292

9. Corpus RA, House JA, Marso SP et al. Multivessel percutaneous coronary intervention in patients with multivessel disease and acute myocardial infarction. Am Heart J 2004; 148: 493– 500.

10. Khattab AA, Abdel‑ Wahab M, Röther C et al. Multi‑vessel stenting during primary percutaneous coronary intervention for acute myocardial infarction: a singlecenter experience. Clin Res Cardiol 2008; 97: 32– 38.

11. Rigattieri S, Biondi‑ Zoccai G, Silvestri P et al. Management of multivessel coronary disease after ST elevation myocardial infarction treated by primary angioplasty. J Interv Cardiol 2008; 21: 1– 7.

12. Kornowski R, Mehran R, Dangas G et al. Prognostic impact of staged vs. "one‑ time" multivessel percutaneous intervention in acute myocardial infarction: analysis from the HORIZONS‑ AMI (harmonizing outcomes with revascularization and stents in acute myocardial infarction) trial. J Am Coll Cardiol 2011; 58: 704– 711.

13. Ochala A, Smolka GA, Wojakowski W et al. The function of the left ventricle after complete multivessel one‑stage percutaneous coronary intervention in patients with acute myocardial infarction. J Invasive Cardiol 2004; 16: 699– 702.

14. Vlaar PJ, Mahmoud KD, Holmes DR Jr. et al. Culprit vessel only vs. multivessel and staged percutaneous coronary intervention for multivessel disease in patients presenting with ST‑segment elevation myocardial infarction: a pairwise and network meta‑analysis. J Am Coll Cardiol 2011; 58: 692– 703. doi: 10.1016/ j.jacc.2011.03.046.

15. Abe D, Sato A, Hoshi T et al. Initial culprit‑ only versus initial multivessel percutaneous coronary intervention in patients with ST‑segment elevation myocardial infarction: results from the Ibaraki Cardiovascular Assessment Study registry. Heart Vessels 2014; 29: 171– 177. doi: 10.1007/ s00380‑ 013‑ 0342‑ 1.

16. Varani E, Balducelli M, Aquilina M et al. Single or multivessel percutaneous coronary intervention in ST‑elevation myocardial infarction patients. Catheter Cardiovasc Interv 2008; 72: 927– 933. doi: 10.1002/ ccd.21722.

17. Hannan EL, Samadashvili Z, Walford G et al. Culprit vessel percutaneous coronary intervention versus multivessel and staged percutaneous coronary intervention for ST‑segment elevation myocardial infarction patients with multivessel disease. JACC Cardiovasc Interv 2010; 3: 22– 31. doi: 10.1016/ j.jcin.2009.10.017.

18. Dambrink JH, Debrauwere JP, Hof AW et al. Non‑ culprit lesions detected during primary PCI: treat invasively or follow the guidelines? EuroIntervention 2010; 5: 968– 975.

19. Politi L, Sgura F, Rossi R et al. A randomised trial of target‑ vessel vs. multi‑vessel revascularisation in ST‑elevation myocardial infarction: major adverse cardiac events during longterm follow‑up. Heart 2010; 96: 662– 667. doi: 10.1136/ hrt.2009.177162.

20. Manari A, Varani E, Guastaroba P et al. Long‑term outcome in patients with ST segment elevation myocardial infarction and multivessel disease treated with culprit‑ only, immediate, or staged multivessel percutaneous revascularization strategies: Insights from the REAL registry. Catheter Cardiovasc Interv. 2014; 84: 912– 922. doi: 10.1002/ ccd.25374.

21. Wald DS, Morris JK, Wald NJ et al. Randomized trial of preventive angioplasty in myocardial infarction. N Engl J Med 2013; 369: 1115– 1123. doi: 10.1056/ NEJMoa1305520.

22. Gershlick AH, Khan JN, Kelly DJ et al. Randomized trial of complete versus lesion‑ only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel disease: the CvLPRIT trial. J Am Coll Cardiol 2015; 65: 963– 972. doi: 10.1016/ j.jacc.2014.12.038.

23. Engstroem T. The third Danish study of optimal acute treatment of patients with ST‑segment elevation myocardial infarction primary PCI in multivessel disease DANAMI3– PRIMULTI. San Diego: ACC 2015.

24. El‑ Hayek GE, Gershlick AH, Hong MK et al. Meta‑Analysis of Randomized Controlled Trials Comparing Multivessel Versus Culprit‑ Only Revascularization for Patients With ST‑Segment Elevation Myocardial Infarction and Multivessel Disease Undergoing Primary Percutaneous Coronary Intervention. Am J Cardiol 2015; 115: 1481– 1486. doi: 10.1016/ j.amjcard.2015.02.046.

25. Bainey KR, Mehta SR, Lai T et al. Complete vs culprit‑ only revascularization for patients with multivessel disease undergoing primary percutaneous coronary intervention for ST‑segment elevation myocardial infarction: A systemic review and meta‑analysis. Am Heart J 2014; 167: 1– 14. doi: 10.1016/ j.ahj.2013.09.018.

26. Sarathy K, Nagaraja V, Kapur A et al. Target‑ vessel versus multivessel revascularisation in st‑ elevation myocardial infarction: a meta‑analysis of randomised trials. Heart Lung Circ 2014; 24: 327– 334. doi: 10.1016/ j.hlc.2014.10.013.

27. Moretti C, D'Ascenzo F, Quadri G et al. Management of multivessel coronary disease in STEMI patients: a systematic review and meta‑analysis. Int J Cardiol 2015; 179: 552– 557. doi: 10.1016/ j.ijcard.2014.10.035.

28. Yeh RW, Drachman DE. Culprit only, multivessel, or staged multivessel intervention in STEMI: new insights or insurmountable methodologic obstacles? Catheter Cardiovasc Interv 2014; 84: 923– 924. doi: 10.1002/ ccd.25673.

29. Widimsky P, Holmes DR. How to treat patients with ST‑elevation acute myocardial infarction and multi‑vessel disease? Eur Heart J 2011; 32: 396– 403. doi: 10.1093/ eurheartj/ ehq410.

30. Bailey SR. Revascularization for ST segment elevation MI: advances in treatment of multivessel disease in STEMI. Catheter Cardiovasc Interv 2014; 84: 857– 858.

31. Pollack A, Mohanty BD, Handa R et al. Preventive Stenting in Acute Myocardial Infarction. JACC Cardiovasc Interv 2015; 8: 131– 138. doi: 10.1016/ j.jcin.2014.09.006.

32. Goldstein JA, Demetriou D, Grines CL et al. Multiple complex coronary plaques in patients with acute myocardial infarction. N Engl J Med 2000; 343: 915– 922.

33. Takano M, Inami S, Ishibashi F et al. Angioscopic follow‑up study of coronary ruptured plaques in nonculprit lesions. J Am Coll Cardiol 2005; 45: 652– 658.

34. Ambrose JA, D'Agate DJ. Plaque rupture and intracoronary thrombus in nonculprit vessels: an eyewitness account. J Am Coll Cardiol 2005; 45: 659– 660.

35. Glaser R, Selzer F, Faxon DP et al. Clinical progression of incidental, asymptomatic lesions discovered during culprit vessel coronary intervention. Circulation 2005; 111: 143– 149.