Safety of Single- Versus Multi-vessel Angioplasty for Patients with AMI and Multi-vessel CAD

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1 Safety of Single- Versus Multi-vessel Angioplasty for Patients with AMI and Multi-vessel CAD Mun K. Hong, MD Associate Professor of Medicine Director, Cardiovascular Intervention and Research Weill Cornell Medical College New York Presbyterian Hospital

2 RCA on Presentation

3 LCX on Presentation

4 LAD on Presentation

5 History 34-year old man PMH: current smoker; no other medical conditions or medications; no illicit drug use FH: (+) premature CAD, with father having MI at age 44 (+) troponin level; no ECG changes What is the appropriate treatment?

6 LCX post Stenting

7 LAD post Stenting

8 RCA post Stenting

9 Background Conventional strategy for primary or rescue angioplasty during acute myocardial infarction (AMI) is angioplasty (PCI) of the infarct-related vessel only regardless of the number of diseased vessels. However, recent studies suggest that acute coronary syndromes, including AMI, may result from a systemic inflammatory process, causing multiple unstable lesions. Many angiographic studies have documented that at least 50% of patients with AMI have multi-vessel CAD. Thus, a strategy of multi-vessel angioplasty in the periinfarct period may be important in improving the outcomes of primary angioplasty.

10 Pros and Cons of Multi-vessel PCI during AMI Pros Complete revascularization, obviating the need for repeat interventions Compensatory hyperkinesis to maintain left ventricular function Prevention of recurrent ischemia or infarction Improved left ventricular function and survival Cons Potentially increased procedural risks Contrast volume Higher late TVR and MACE Unnecessary revascularization

11 Purpose To determine the feasibility and safety of multi-vessel PCI compared to single-vessel PCI in patients with AMI and multi-vessel (>70% stenosis in at least 2 major coronary arteries).

12 Methods Using the New York State Angioplasty Registry database, we retrospectively compared inhospital clinical outcomes in patients with multi-vessel disease who underwent single vessel, infarct-related vessel PCI only versus multi-vessel PCI within 24 hours of AMI. Patients with cardiogenic shock or hemodynamic instability, prior myocardial infarction, PCI, or coronary artery bypass surgery were excluded from the analysis.

13 Methods Multivessel disease was defined as having > 70% stenosis in at least two major coronary arteries. Post procedural major adverse cardiac events (MACE) were defined as in-hospital death, stroke, or need for emergent coronary artery bypass surgery. Other outcome measures included length of stay and renal failure requiring dialysis.

14 Results:Baseline Characteristics Single-vessel PCI Multi-vessel PCI P Value (N=1381) (N=642) Age (years) 62.3± ± Male (%) Hypertension (%) NS Diabetes (%) Tobacco use (%) NS Prior stroke (%) Chronic renal failure*(%) NS Peripheral vascular disease(%) * Chronic renal failure: serum creatinine >2.5 mg/dl or dependence on peritoneal or hemodialysis

15 Results:Procedural Characteristics Single vessel PCI Multi vessel PCI P Value (N=1381) (N=642) Congestive heart failure (%) NS Ejection Fraction (%) 46.4± ±10.6 NS GP IIb/IIIa inhibitor therapy (%) NS Thrombolytic therapy (%) NS PCI total occlusion (%) <0.001 PCI proximal LAD (%) <0.001 Proximal LAD lesion present, no PCI (%) <0.001 Stent (%) <0.001

16 Results:Angiographic Characteristics Single vessel PCI Multi vessel PCI P Value (N=1381) (N=642) Number of lesions >70%, per patient <0.001 Lesion Type per group (%) A <0.001 B <0.001 C <0.001 Total lesions treated/lesions present (%) 2416/4482 (53.9) 2109/2242 (94.1) <0.001

17 Results In-hospital outcomes Prevalence (%) * * * p< Single vessel PCI (n=1381) Multi-vessel PCI (n=642) MACE Death Emergent CABG Stroke

18 Results There were no differences between the groups in: acute occlusion or stent thrombosis (0.7% versus 0.9%) acute renal failure requiring dialysis (0.2% versus 0.3%) length of stay (5.4 versus 5.3 days).

19 Results Independent predictors of mortality Multi-vessel PCI Proximal LAD lesion Congestive heart failure Increasing Age

20 Conclusions Despite the added complexity of multi-vessel PCI, patients in this group had significantly lower inhospital mortality. A strategy of multi-vessel PCI during AMI may be safe compared with infarct-related artery angioplasty in selected patients.