Cindy L. Grines MD FACC FSCAI

Transcription

1 Cindy L. Grines MD FACC FSCAI Hofstra Northwell School of Medicine Chair, Cardiology Academic Chief of Cardiology, Northwell Health North Shore University Hospital, Manhasset NY

2 Multivessel Disease in AMI Multivessel disease occurs in 40-60% of patients with STEMI, and 70-80% of patients with shock It confers higher risk of death, reinfarction, stent thrombosis, lack of compensatory hyperkinesis of the non-infarct zone and development of shock Multiple culprits may be present due to a systemic inflammatory state Therefore, treatment of non-culprit vessels may be beneficial

3 The Case for Not Performing Multi-Vessel PCI during Infarct Angioplasty Every PCI for every lesion increases the risk (enhanced thrombotic and inflammatory state during STEMI) Longer more complex procedures (contrast nephropathy, hemodynamic instability) Additional time, cost, more radiation exposure Non-culprit lesion severity is often exaggerated during AMI Follow up angios showed 20% of significant lesions were now less than 50% narrowed (JACC 2002;40:911-6) FFR negative in 40% of significant lesions (Euro Intervention 2010;5:968)

4 American Guidelines prior to 2015: PCI should not be performed in a noninfarct artery (Class III) Current Guidelines Class IIb

5 ESC STEMI Guidelines 2017 Eur Heart J. Published online August 26, doi: /eurheartj/ehx393

6 Freedom from Primary Outcome (%) PRAMI: Preventative PCI of Non-culprit Lsns after Culprit Lesion Primary PCI in STEMI 465 non-shock pts at 5 UK sites with MVD; after successful primary PCI randomized to NCL PCI of non-lm DS 50-99% stenoses vs. conservative care 600 pts planned; DSMB stopped trial early after 465 pts enrolled ( ) Primary endpoint: Cardiac death, MI or refractory angina Complete revasc Culprit PCI only 91% 77% HR 0.35 (95%CI ) P<0.001 No. at Risk Preventive PCI No Preventive PCI Months Wald DS et al. NEJM 2013:on-line

7 PRAMI Results

8 Criticisms of the PRAMI study Small sample size and stopped prematurely Reported benefits are too extreme to be real Non-infarct vessels did not undergo FFR or QCA uncertain of severity Early reinfarction from the nonculprit vessel missed since enzymes are already elevated Limited applicability we do not treat 50% lesions or ignore tight lesions

9 Cv LPRIT Study: MVD >70% lesion in Non IRA, >2mm diameter (68% acute, 32% staged) ESC 2014

10 CvLPRIT Clinical Outcomes (Primary Endpoint) at 12 months (Per Protocol Population) Variable IRA Only Multi-vessel PCI IRA plus N- IRA HR (95% CI) MACE 28/138 (20.3) 9/136 (6.6) 0.31 (0.15, 0.65) All-cause mortality 5/138 (3.6) 1/136 (0.7) 0.20(0.02, 1.73) Recurrent MI 4/138 (2.9) 2/136 (1.5) 0.50 (0.09, 2.74) Heart failure 7/138 (5.1) 3/136 (2.2) 0.43 (0.11, 1.66) Repeat Revasc 12/138 (8.7) 3/136 (2.2).24 (0.07, 0.85) Death/MI 14/146 (9.6) 6/150 (4.0) P ESC 2014

11 PRAGUE-13 Staged PCI at 3-40 days Primary Composite Endpoint PCI (n=106) Conservative (n=108) Hazard ratio (95% CI) p-value All-cause mortality/non fatal MI/stroke All-cause mortality 17 (16.0%) 15 (13.9%) 1.35 ( ) 6 (5.7%) 7 (6.5%) 0.91 ( ) Nonfatal MI 11(10.4%) 8 (7.4%) 1.71 ( ) Stroke 0 3 (2.8%) 4 (3.8%) periprocedural infarctions in PCI group with good prognosis

12 PRAGUE-13 Secondary Endpoints Hazard ratio (95% CI) P-value Hospitalization for unstable angina 0.52 ( ) Crossover to another treatment group 0.25 ( ) Revascularization of non-infarct artery 0.51 ( ) Cardiovascular mortality ( ) All-cause mortality + nonfatal myocardial infarction + hospitalization for unstable angina All-cause mortality + nonfatal myocardial infarction + revascularization 1.03 ( ) ( ) Hospitalization for heart failure 0.68 ( ) Cardiovascularmortality + nonfatal myofcardial infarction + revascularization 0.92 ( ) No non-infarct lesion progressed to myocardial infarction during follow-up. Progression of studied non-infarct lesions was very rare

13 Should All Lesions be Treated? PRAMI:The tightest lesions have the worst outcomes Stenosis Severity and Outcomes Stenosis % No Preventive PCI Primary outcome event Percentage with event % (10/74) * 23% (32/130) % (11/27) All % (53/231) * p for trend <0.01

14 Angiography is not ideal to determine lesion severity. Should we perform FFR? If so, when?

15 FFR and complete revascularization performed 2 days post-mi. 31% had negative FFR

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17 Network Meta-analysis of 10 randomized STEMI trials: No difference in Hard Endpoints, Staging is Preferred Islam Y. Elgendy et al. JACC interventions 2017;10: American College of Cardiology Foundation

18 Do you need to wait 2 days to perform FFR, or can it be done acutely?

19 OMPARE-ACUTE

20 COMPARE-ACUTE FFR of Non-IRA is abnormal in 50% Outcomes based on FFR and management

21 COMPARE-ACUTE: Primary Outcome

22 COMPARE-ACUTE Primary Outcome and Components FFR-guided Complete (295) IRA-only (590) Hazard Ratio P Value MACCE 23 (7.8%) 121 (20.5%) 0.35 <0.001 All-Cause Mortality 4 (1.3%) 10 (1.7%) Cardiac Mortality 3 (1.0%) 6 (1.0%) Myocardial Infarction 7 (2.4%) 28 (4.7%) Revascularization 18 (6.1%) 103 (17.5%) 0.32 <0.001 Stroke 0 4 (0.7%) NA NA

23 Shouldn t the sickest patients benefit the most from complete revascularization?

24 CULPRIT-SHOCK: A Randomized Trial of Multivessel PCI in Cardiogenic Shock Holger Thiele, MD on behalf of the CULPRIT-SHOCK Investigators

25 All-cause mortality (%) All-Cause Mortality Immediate multivessel PCI 51.5% 43.3% Culprit lesion only PCI Number at risk: Culprit lesion only PCI 10 0 Relative risk 0.84; 95% confidence interval ; P= Days after randomization Immediate multivessel PCI

26 Subgroup Analysis Primary Endpoint Baseline Variable Multivessel PCI Culprit lesion only PCI Relative Risk (95% CI) P Value for Interaction Sex Male 148/266 (55.6) 109/257 (42.4) 0.76 ( ) 0.11 Female 41/75 (54.7) 48/86 (55.8) 1.02 ( ) Age <50 years 3/16 (18.8) 6/17 (35.3) 1.88 ( ) years 114/226 (50.4) 82/212 (38.7) 0.77 ( ) >75 years 72/99 (72.7) 70/115 (60.1) 0.84 ( ) Diabetes No 116/218 (53.2) 93/235 (39.6) 0.74 ( ) 0.08 Yes 66/116 (56.9) 59/102 (57.8) 1.02 ( ) Hypertension No 68/129 (52.7) 65/139 (46.8) 0.89 ( ) 0.47 Yes 114/205 (55.6) 88/200 (44.0) 0.79 ( ) Type of infarction NSTEMI 54/97 (55.7) 45/98 (45.9) 0.82 ( ) 0.96 STEMI 128/233 (54.9) 108/237 (45.6) 0.83 ( ) STEMI type Anterior infarction 59/113 (52.2) 57/108 (52.8) 1.01 ( ) 0.07 Non-anterior infarction 48/92 (52.2) 34/97 (35.0) 0.67 ( ) Previous infarction No 154/281 (54.8) 128/279 (45.9) 0.84 ( ) 0.83 Yes 28/53 (52.8) 25/60 (41.7) 0.79 ( ) Coronary artery disease 2-vessel disease 64/124 (51.6) 48/122 (39.3) 0.76 ( ) vessel disease 124/215 (57.7) 109/218 (50.0) 0.87 ( ) Chronic total occlusion No 146/259 (56.4) 131/267 (49.1) 0.87 ( ) 0.26 Yes 43/82 (52.4) 27/77 (35.1) 0.67 ( ) Culprit 0 lesion only 1 PCI better 2 3 Multivessel PCI better

27 STEMI with Multivessel Disease Multivessel disease = worse outcomes Recent studies suggest complete revascularization may be beneficial but: Benefit may be confined to reduction in ischemia rather than hard endpoints. Harm in shock pts? Identification of which lesions benefit (likely abnormal FFR/iFR or tight stenosis) and the appropriate timing of PCI is unclear First do no harm: consider staged PCI to reduce contrast induced renal failure, allow antiplatelets to become therapeutic and vasomotion of noninfarct vessels to normalize.

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