Strategies And Optimal Timing Of Percutaneous Revascularization For Patients With ST-segment Elevation Myocardial Infarction And Multivessel Coronary Artery Disease

Part 1Objective To explore the impact of culprit-vessel only percutaneous coronary intervention(PCI)versus complete PCI on clinical outcomes of patients with ST-segment Elevation Myocardial Infarction(STEMI)and Multivessel Disease(MVD).Methods We retrospectively analyzed a total of 326 patients who presented with STEMI and MVD and who were admitted in the intensive care unit of cardiology of Xijing Hospital from January 1,2009 to June 30,2014.MVD was defined as the presence of stenosis of 70% or greater in at least two more major epicardial coronary artery(with diameter ≥ 2.0 mm).After completing revascularization of the culprit vessel within 12 hours of onset,131 patients agreed to undergo revascularization of the non-culprit arteries during the same procedure of the primary PCI or at 1 to 60 days after the primary PCI(complete revascularization).Then a total of 195 patients received PCI only for the culprit vessel.The primary endpoint was a composite of cardiac death,recurrent myocardial infarction,ischemia-driven revascularization and heart failure within 3 years.Other endpoints included the components of the primary endpoints,all-cause death,refractory angina and all bleedings(BARC 1~5)at 3 years follow-up.And a Cox proportional hazards model would be established to determine if the revascularization strategy was an independent risk factor associated with MACE of patients presented with STEMI and MVD after adjusting the confounding factors.Results Compared to a culprit-vessel only revascularization strategy,the complete revascularization resulted in a lower rate of MACE(17.6% vs.30.8%,P = 0.005),cardiac death(1.5% vs.7.7%,P = 0.029),heart failure(1.5% vs.7.2%,P = 0.031)and all-cause death(2.3% vs.9.2%,P = 0.022).The rates of recurrent myocardial infarction(3.8% vs.2.6%,P = 0.622),ischemia-driven revascularization(14.5% vs.17.9%,P = 0.246),refractory angina(24.4% vs.27.2%,P = 0.332)and all bleedings(3.8% vs.3.1%,P = 0.793)were similar between the two strategies.The analysis of the established Cox proportional hazards model showed that the complete revascularization strategy(HR: 0.47,95%CI: 0.29-0.76)was an independent protective factor after adjusting the confounding factors.Other risk factors included the higher class of the Killip(Class III/Ⅳ)(HR: 3.99,95%CI: 1.86-8.55),the culprit vessel of left anterior descending branch(LAD)(HR: 2.75,95%CI: 1.60-4.73)and left circumflex(LCX)(HR: 3.78,95%CI: 1.82-7.86)(compared to right coronary artery(RCA)).Conclusions Compared to the strategy of culprit-vessel only revascularization,the complete revascularization for patients with STEMI and MVD could significantly reduce the risk of MACE at 3 years follow-up.Part 2Objective To explore the optimal timing of the complete revascularization strategy for patients presented with STEMI and MVD.Methods A total of 131 selected patients with STEMI and MVD were divided into patients who received non-culprit arteries revascularization during the same procedure as the primary PCI(MV-PCI,21 cases),ones who underwent revascularization of the non-culprit arteries at 1 to 7 days(7d staged-PCI,82 cases)and 8 to 60 days(60d staged-PCI,28 cases)after the primary PCI according to the timing of PCI for the non-culprit arteries.The 7d staged-PCI and the 60 d staged-PCI group made up of the Staged-PCI group.The primary endpoint was a composite of cardiac death,recurrent myocardial infarction,ischemia-driven revascularization and heart failure within 3 years.Other endpoints included the components of the primary endpoints,all-cause death,refractory angina and all bleedings(BARC 1~5)at 3 years follow-up.This study also compared the difference of the overall costs and inpatient time among the three complete revascularization groups.Results(1)Compared to the MV-PCI,the Staged-PCI did not reduce the rate of MACE(17.3% vs.19.0%,P = 0.921)and all bleedings(BARC 1~5)(3.6% vs.4.8%,P = 0.818)at 3 years follow-up.There were also no significant difference in components of MACE,all-cause death and refractory angina(P > 0.05)between the two strategies.Although the comparison of MV-PCI,7d staged-PCI and 60 d staged-PCI demonstrated no difference in the prespecified endpoints,the rates of MACE(7.1% vs.19.0%,20.7%,P = 0.274),ischemia-driven revascularization(7.1% vs.19.0%,15.9%,P = 0.454)and all bleedings(BARC 1~5)(0% vs.4.8%,4.9%,P = 0.496)of 60 d staged-PCI were numerically lower than the other two groups.In the comparison of complete PCI vs.culprit-vessel only PCI,the Staged-PCI(17.3% vs.30.8%,P = 0.009)and 60 d staged-PCI(7.1% vs.30.8%,P = 0.012)resulted in lower MACE rates.While both the 7d staged-PCI vs.the Culprit-Only PCI(20.7% vs.30.8%,P = 0.073)and the MV-PCI vs.the the Culprit-Only PCI(19.0% vs.30.8%,P = 0.226)showed no significant difference.(2)The average inpatient time and overall cost of the MV-PCI group were the least among the three groups.And those of the 60 d staged-PCI group were the most.Conclusions Although the comparison of MV-PCI,7d staged-PCI and 60 d staged-PCI demonstrated no difference in the prespecified endpoints,the rates of MACE,ischemia-driven revascularization and all bleedings(BARC 1~5)of 60 d staged-PCI were numerically lower than the other two groups,which indicated that the strategy of 60 d staged-PCI was better for the patients with STEMI and MVD.At last,the findings of our study need verifying by a multi-center,larger sample,randomized controlled study.