should we dilate the non- infarct related arteries in patients with multi-vessel disease? carma...
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Should we dilate the non-Should we dilate the non-infarct related arteries in infarct related arteries in patients with multi-vessel patients with multi-vessel
disease?disease?
Carma Karam, MDCarma Karam, MDCardiologistCardiologist
AIHP, ACCA, FACCAIHP, ACCA, FACCClinique Clinique Médicale du RingMédicale du Ring
Since 1980, we know that AMI is Since 1980, we know that AMI is related to coronary occlusion and related to coronary occlusion and
therefore the preferred therapy is to therefore the preferred therapy is to open the IRAopen the IRA
Prevalence of total coronary occlusion during Prevalence of total coronary occlusion during the early hours of transmural myocardial the early hours of transmural myocardial
infarction.infarction.
DeWood MA, et al N Engl J Med. 1980 Oct DeWood MA, et al N Engl J Med. 1980 Oct 16;303(16):897-902.16;303(16):897-902.
Decreased prevalence of late potentials with mechanical versus Decreased prevalence of late potentials with mechanical versus thrombolysis-induced reperfusion in acute myocardial infarctionthrombolysis-induced reperfusion in acute myocardial infarction
Karam C, JLG, PGS, et al Karam C, JLG, PGS, et alHôpitalHôpital Bichat, France Bichat, France
J Am Coll Cardiol, 1996; 27:1343-1348J Am Coll Cardiol, 1996; 27:1343-1348
Many authors have shown that Many authors have shown that reperfusion obtained by angioplasty reperfusion obtained by angioplasty is superior to reperfusion obtained is superior to reperfusion obtained
with thrombolyticswith thrombolytics
Should we dilate the non-Should we dilate the non-infarct related arteries in infarct related arteries in
patients with MVD?patients with MVD?
Di Mario et al. assigned 69 STEMI patients with Di Mario et al. assigned 69 STEMI patients with multivessel disease to unbalanced multivessel disease to unbalanced
randomization with culprit lesion treatment only randomization with culprit lesion treatment only (n = 17) versus complete multivessel (n = 17) versus complete multivessel intervention (n = 52). The multivessel intervention (n = 52). The multivessel
intervention group required longer procedures intervention group required longer procedures and larger amounts of contrast, but only had a and larger amounts of contrast, but only had a trend for lower revascularization requirements trend for lower revascularization requirements
at 12 months.at 12 months.
Di Mario C, Mara S, Flavio A, et al. (HELP-AMI) study Int J Cardiovasc Interv 2004;6:128-133
Politi et al. : 214 STEMI pts with MVD culprit vessel PCI Politi et al. : 214 STEMI pts with MVD culprit vessel PCI alone (n = 84), simultaneous treatment of nonculprit (n alone (n = 84), simultaneous treatment of nonculprit (n
= 65), or culprit only + staged revascularization (n = 65). = 65), or culprit only + staged revascularization (n = 65). In-hospital mortality, unplanned rehospitalization, and In-hospital mortality, unplanned rehospitalization, and repeat revascularization more frequent in the culprit-repeat revascularization more frequent in the culprit-
vessel-only (all p < 0.05). vessel-only (all p < 0.05).
Requirement for repeat revascularization in the culprit-Requirement for repeat revascularization in the culprit-only strategy should not be considered a major adverse only strategy should not be considered a major adverse event, but rather interpreted within a global strategy in event, but rather interpreted within a global strategy in
which closer clinical follow-up is needed. which closer clinical follow-up is needed.
The sample size of these studies was grossly The sample size of these studies was grossly underpowered to detect differences in death or underpowered to detect differences in death or
recurrent MI.recurrent MI.Politi L, Sgura F, Rossi R, et al. Heart 2009 Sep 23
Multivessel intervention during primary Multivessel intervention during primary PCIPCI
Few studiesFew studies
Small number of patients Small number of patients
Trend but no statistically significant differenceTrend but no statistically significant difference
Questionable endpointsQuestionable endpoints
Underpowered sample sizeUnderpowered sample size
Randomization bias?Randomization bias?
Possible selection biasPossible selection bias
Successful culprit vessel stenting readily accomplished Successful culprit vessel stenting readily accomplished during a smooth procedure, leading to TIMI coronary during a smooth procedure, leading to TIMI coronary
flow grade 3 and nearly complete ST-segment flow grade 3 and nearly complete ST-segment resolution. resolution.
If another easy/attractive target is identified in this If another easy/attractive target is identified in this patient, the temptation to finish the procedure achieving patient, the temptation to finish the procedure achieving
complete revascularization might be high. complete revascularization might be high.
Conversely, a complex, prolonged procedure required to Conversely, a complex, prolonged procedure required to open the culprit lesion will likely discourage the operator open the culprit lesion will likely discourage the operator
from further attempts in other vessels.from further attempts in other vessels.
Fortunately, a recent study published Fortunately, a recent study published in 2010 helps answer in 2010 helps answer
the questions concerning culprit vessel the questions concerning culprit vessel only versus multivessel intervention only versus multivessel intervention
during primary PCIduring primary PCI
Culprit Vessel Percutaneous Coronary Culprit Vessel Percutaneous Coronary Intervention Versus Multivessel and Intervention Versus Multivessel and Staged Percutaneous Coronary Staged Percutaneous Coronary Intervention for ST-Segment Elevation Intervention for ST-Segment Elevation Myocardial Infarction Patients With Myocardial Infarction Patients With Multivessel DiseaseMultivessel Disease
Edward L. Hannan, Zaza Samadashvili, Edward L. Hannan, Zaza Samadashvili, Gary Walford, David R. Holmes, Jr, Gary Walford, David R. Holmes, Jr, Alice K. Jacobs, Nicholas J.Stamato,Alice K. Jacobs, Nicholas J.Stamato,
Ferdinand J. Venditti, Samin Sharma, Ferdinand J. Venditti, Samin Sharma, Spencer B. King, IIISpencer B. King, III
JACC Cardiovasc Interv 2010;3:22-31.JACC Cardiovasc Interv 2010;3:22-31.
ObjectivesObjectives
The purpose of this study was to examine the The purpose of this study was to examine the differences in in-hospital and longer-term differences in in-hospital and longer-term
mortality for STEMI pts with MVD as a function mortality for STEMI pts with MVD as a function of whether they underwent single-vessel (culprit of whether they underwent single-vessel (culprit vessel) percutaneous coronary interventions or vessel) percutaneous coronary interventions or
multivessel PCImultivessel PCI
JACC Cardiovasc Interv 2010;3:22-31.JACC Cardiovasc Interv 2010;3:22-31.
What is the best time to intervene on nonculprit What is the best time to intervene on nonculprit vessels ?vessels ?
New York between January 2003, and June 2006New York between January 2003, and June 2006
1-Pts who underwent culprit vessel PCI only 1-Pts who underwent culprit vessel PCI only 2-Pts who underwent multivessel PCI during the index 2-Pts who underwent multivessel PCI during the index procedureprocedure3-Pts undergoing nonculprit vessel PCI during the index 3-Pts undergoing nonculprit vessel PCI during the index admissionadmission4-Pts undergoing staged PCI to the nonculprit vessel within 4-Pts undergoing staged PCI to the nonculprit vessel within 60 days of admission60 days of admission
JACC Cardiovasc Interv 2010;3:22-31.JACC Cardiovasc Interv 2010;3:22-31.
MethodsMethods
Total of 4,024 ptsTotal of 4,024 pts
3,521 pts (87.5%) culprit vessel PCI only3,521 pts (87.5%) culprit vessel PCI only
Staged PCI during the index admission in 259 Staged PCI during the index admission in 259 pts (6.43%) pts (6.43%)
538 pts staged PCI within 60 days (13.37%).538 pts staged PCI within 60 days (13.37%).
JACC Cardiovasc Interv 2010;3:22-31.JACC Cardiovasc Interv 2010;3:22-31.
ResultsResults
Pts without hemodynamic compromise :Pts without hemodynamic compromise :Culprit vessel PCI lower in-hospital mortality than Culprit vessel PCI lower in-hospital mortality than
multivessel PCI during the index procedure multivessel PCI during the index procedure (0.9% vs. 2.4%, p = 0.04). (0.9% vs. 2.4%, p = 0.04).
Culprit vessel only vs nonculprit vessel during the same Culprit vessel only vs nonculprit vessel during the same hospitalization : No difference in outcome. hospitalization : No difference in outcome.
Staged multivessel PCI within 60 days : Staged multivessel PCI within 60 days : lower 12-mth mortality than culprit vessel PCI only lower 12-mth mortality than culprit vessel PCI only
(1.3% vs. 3.3%, p = 0.04).(1.3% vs. 3.3%, p = 0.04).JACC Cardiovasc Interv 2010;3:22-JACC Cardiovasc Interv 2010;3:22-
31.31.
A strategy of culprit vessel PCI only at the time A strategy of culprit vessel PCI only at the time of STEMI is associated with the best outcome in of STEMI is associated with the best outcome in
pts with MVD.pts with MVD.
Multicenter population-based study Multicenter population-based study The only one that examines long-term The only one that examines long-term
outcomes and the use of multivessel PCI after outcomes and the use of multivessel PCI after discharge as well as during the index discharge as well as during the index
admission.admission.
ConclusionConclusionof the studyof the study
Current ACC/AHA guidelines recommend culprit vessel Current ACC/AHA guidelines recommend culprit vessel PCI only in pts undergoing primary PCI (unless there is PCI only in pts undergoing primary PCI (unless there is
hemodynamic compromise) hemodynamic compromise)
This study corroborates these findings This study corroborates these findings
Since there are no data to the contrary, culprit vessel Since there are no data to the contrary, culprit vessel PCI only should remain the preferred revascularization PCI only should remain the preferred revascularization
strategy, and if there is an indication for PCI of a strategy, and if there is an indication for PCI of a nonculprit vessel, such a procedure should be nonculprit vessel, such a procedure should be
performed in a staged fashion performed in a staged fashion
The optimal timing of such a staged procedure, The optimal timing of such a staged procedure,
however, remains unclearhowever, remains unclear
Non culprit vessels primary Non culprit vessels primary intervention may lead to:intervention may lead to:
Prolonged interventions Prolonged interventions
Non culprit vessels primary Non culprit vessels primary intervention may lead to: intervention may lead to:
Contrast overload Contrast overload
Non culprit vessels primary interventionNon culprit vessels primary intervention may lead may lead to:to:
Renal impairment Renal impairment and Heart Failureand Heart Failure
Nonculprit lesion severity may be Nonculprit lesion severity may be exaggerated as the result of circulating exaggerated as the result of circulating
catecholamine-mediated catecholamine-mediated vasoconstriction, and precise evaluation vasoconstriction, and precise evaluation of revascularization requirements may be of revascularization requirements may be
hampered. hampered.
Non culprit vessels primary interventionNon culprit vessels primary intervention may lead to:may lead to:
Jeopardizing myocardial territory that Jeopardizing myocardial territory that would be of special concern in the acute would be of special concern in the acute
phasephase
Non culprit vessels primary Non culprit vessels primary interventionintervention may lead to:may lead to:
High financial costs High financial costs
Non culprit vessels primaryNon culprit vessels primary stenting might be stenting might be associated with higher rates of associated with higher rates of periprocedural periprocedural
MIMI, and with increased rates of late , and with increased rates of late revascularizations secondary to revascularizations secondary to restenosisrestenosis..
Hypothetic favorable effects of primary non-culprit Hypothetic favorable effects of primary non-culprit vessels PCIvessels PCI
Ensuring adequate, complete, early revascularization Ensuring adequate, complete, early revascularization NOT PROVEN NOT PROVEN
Lower requirement of repeated procedures Lower requirement of repeated procedures NOT PROVENNOT PROVEN
Improvement of left ventricular function Improvement of left ventricular function NOT PROVENNOT PROVEN
Reduction of hospital stay Reduction of hospital stay NOT PROVENNOT PROVEN
Reduction in hospital costs Reduction in hospital costsNOT PROVEN NOT PROVEN
Improving long-term clinical outcomeImproving long-term clinical outcomeNOT PROVENNOT PROVEN
Conclusion: Staged procedures for Conclusion: Staged procedures for multivessel disease post culprit multivessel disease post culprit
primary PCIprimary PCI