STEMI AND MULTIVESSEL CORONARY DISEASE

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1 STEMI AND MULTIVESSEL CORONARY DISEASE ΤΣΙΑΦΟΥΤΗΣ Ν. ΙΩΑΝΝΗΣ ΕΠΕΜΒΑΤΙΚΟΣ ΚΑΡΔΙΟΛΟΓΟΣ Α ΚΑΡΔΙΟΛΟΓΙΚΗ ΝΟΣ ΕΡΥΘΡΟΥ ΣΤΑΥΡΟΥ

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3 IRA 30-50% of STEMI patients have additional stenoses other than the infarct related artery 1,2 Current guidelines support culprit vessel PCI only Contemporary studies have, however, suggested preventive revascularisation 3,4 Non culprit 1 Jong JA al. Coronary Artery disease Muller DW et al. Am Heart J Wald et al. NEJM Gershlick et al. ESC 2014

4 DEBATE Is it reasonable treating the nonira during the STEMI pci?? Hypercoagulable inflammatory state Maybe not optimal antiplatelet therapy Non culprit lesions often exaggerated during STEMI (flow,spasm) Even FFR is real in non IRA? Longer procedures, radiation, cost

5 Current practice

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7 Revasc 2014

8 American guidelines (ACC/AHA) I IIa IIb III PCI of a non-infarct artery at the time of primary PCI in patients without hemodynamic compromise is not indicated I IIa IIb III PCI is indicated in a non-infarct artery at a time separate from primary PCI in patients who have spontaneous symptoms of myocardial ischemia. I IIa IIb III PCI is reasonable in a non-infarct artery at a time separate from primary PCI in patients with intermediate- or high-risk findings on noninvasive testing O Gara PT S et al. JACC 2013

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13 Prevalence, Predictors, and In-Hospital Outcomes of Non- Infarct Artery Intervention During Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction (from the National Cardiovascular Data Registry) Matthew A Cavender et al August 2009 The overall in-hospital mortality rates were greater in patients undergoing multivessel PCI (7.9% vs 5.1%, p <0.01). Among patients with STEMI and cardiogenic shock (n = 3,087), those receiving multivessel PCI had greater in-hospital mortality (36.5% vs 27.8%; adjusted odds ratio 1.54, 95% confidence interval 1.22 to 1.95). In conclusion, these data suggest that performing multivessel PCI during primary PCI for STEMI does not improve short-term survival even for patients with cardiogenic shock.

14 Prognostic impact of staged versus "one-time" multivessel percutaneous intervention in acute myocardial infarction: analysis from the HORIZONS-AMI trial. Kornowski R 1, Mehran R, Dangas G, Nikolsky E, Assali A, Claessen BE, Gersh BJ, Wong SC, Witzenbichler B, Guagliumi G, Dudek D, Fahy M, Lansky AJ, Stone GW; HORIZONS-AMI Trial Investigators. Single versus staged PCI was associated with higher 1-year mortality (9.2% vs. 2.3%, p < ), cardiac mortality (6.2% vs. 2.0%; HR: 3.14, p = 0.005), definite/probable stent thrombosis (5.7% vs. 2.3%; HR: 2.49, p = 0.02), and a trend toward greater major adverse cardiovascular events (18.1% vs. 13.4%, p = 0.08). The mortality advantage favoring staged PCI was maintained in a subgroup of patients undergoing truly elective multivessel PCI. Also, the staged PCI strategy was independently associated with lower all-cause mortality at 30 days and at 1 year. J Am Coll Cardiol 2011

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16 Preventive Angioplasty in Myocardial Infarction Trial David S Wald, Joan K Morris, Nicholas J Wald, Alexander J Chase, Richard J Edwards, Liam O Hughes, Colin Berry, Keith G Oldroyd N Engl J Med 2013;369:

17 Trial flow diagram Acute STEMI Successful Infarct-artery PCI Exclusions Previous CABG Cardiogenic Shock Left main stem >50% Chronic total occlusion Multivessel Disease (>50% stenosis in noninfarct-artery suitable for PCI) Randomise 600 (target) Preventive PCI No Preventive PCI Follow-up at 6 weeks and then annually

18 Primary trial outcome One or more of the following: Cardiac death Nonfatal myocardial infarction Refractory angina with evidence of ischaemia

19 Cardiac Death, Nonfatal MI or Refractory Angina in patients having infarct-artery PCI Wald DS et al. NEJM 2013:369: Hazard Ratio 0.35 (95% CI 0.21 to 0.58), p<0.001 Risk Reduction 65% n=234 n=231

20 n=234 n=231 Cardiac Death, Nonfatal MI or Refractory Angina in patients having infarct-artery PCI Wald DS et al. NEJM 2013:369: Hazard Ratio 0.36 (95% CI 0.18 to 0.73), p=0.004 Risk Reduction 64%

21 Proportion without any primary outcome Early Benefit Preventive PCI 0.80 No Preventive PCI Hazard Ratio 0.35 (95% CI 0.21 to 0.58) Months since randomisation Wald DS et al. NEJM 2013:369:

22 Repeat Revascularisation Hazard Ratio 0.30 (95% CI 0.17 to 052), p<0.001 Risk Reduction 70% n=234 n=231

23 Post randomisation medical therapy Preventive PCI No Preventive PCI Aspirin + clopidogrel, prasugrel or ticagrelor 100% 100% Statin 95% 97% Beta-blocker 88% 92% ACE Inhibitor or ARB 93% 91% Wald DS et al. NEJM 2013:369:

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25 CvLPRIT TRIAL

26 CvLPRIT trial

27 CvLPRIT trial

28 CvLPRIT trial

29 CvLPRIT Trial Demonstrated 55% reduction in MACE with no adverse safety signal for complete revascularization during the index admission in patients presenting for PPCI This strategy should be considered by future guidelines committees EuroIntervention Feb 22;8(10):

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31 PRAGUE-13 trial

32 PRAGUE 13 Randomization - 2 groups

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34 PRAGUE 13 Primary composite endpoint

35 PRAGUE-13 Primary composite endpoint

36 PRAGUE-13 Secondary endpoints

37 PRAGUE-13 Conclusion

38 DANAMI-3-PRIMULTI The Third DANish Study of Optimal Acute Treatment of Patients with ST-segment elevation myocardial infarction Complete revascularisation versus treatment of the culprit lesion only in patients with STsegment elevation myocardial infarction and multivessel disease (DANAMI-3 PRIMULTI): an open-label, randomised controlled trial Lancet Aug 15;386(9994):

39 DANAMI3-TRIAL PROGRAM 2239 STEMI < 12 hours Randomise conventional PPCI, ipost, defer stenting 2212 Successful infarct related artery PCI 627 Multivessel disease (>50% stenosis in non IRA > 2 mm suitable for PCI) Randomise 313 IRA PCI only 314 FFR guided complete revascularisation

40 But what about FFR and STEMI? Fractional flow reserve for the assessment of nonculprit coronary artery stenoses in patients with acute myocardial infarction. Ntalianis A,..Hamilos M,..De Bruyne JACC Cardiovasc Interv 2010 Dec The FFR measurements in 112 nonculprit stenoses were obtained immediately after PCI of the culprit stenosis and were repeated 35 ± 4 days later. The FFR value of the nonculprit stenoses did not change between the acute and follow-up

41 Primary endpoint Composite All-cause mortality Nonfatal myocardial infarction Ischemia driven revascularisation of non IRA lesions Assessed when the last included patient had been followed for 1 year

42 Complications IRA only (n = 313) Complete revascularisation (n = 314) P Periprocedural myocardial infarction 0 2 (0 6) 0 2 Bleeding requiring transfusion or surgery 4 (1 3) 1 (0 3) 0 2 CIN (>50% rise in p-creatinine) 7 (2 2) 6 (1 9) 0 8 Stroke 1 (0 3) 4 (1 3) 0 2 DANAMI3-PRIMULTI

43 Individual components of primary endpoint Composite Revascularisation Non fatal MI All cause death DANAMI3-PRIMULTI

44 Event rate (%) Endpoints p= p< p=0.47 p=0.002 p=0.43 p= p= p= DANAMI3-PRIMULTI

45 Conclusions Complete FFR guided revascularisation of multivessel disease in STEMI patients, staged within the index admission, reduced the primary endpoint of all cause death, reinfarction and repeat revascularisation 40% of repeat revascularisations were urgent However, the reduction in the primary endpoint was driven by repeat revascularisations and not by hard endpoints Therefore, although complete revascularisation should be recommended, any condition that makes complex PCI unattractive may support a more conservative strategy of IRA PCI only DANAMI3-PRIMULTI

46 CTO in non-ira in 10% of STEMI patients Excess mortality in MVD patients mainly driven by presence of CTO Reduced LV function in MVD patients mainly driven by presence of CTO

47 Explore Trial Design Patients Patients with STEMI treated with ppci and with a non-infarct related CTO. Design Global, multi-center, randomized, prospective two-arm trial with either PCI of the CTO or no CTO intervention after STEMI. Blinded evaluation of endpoints. CTO-PCI < 7d Patients with STEMI + CTO 1:1 No CTO-PCI Objective To determine whether PCI of the CTO within 7 days after STEMI results in a higher LVEF and a lower LVEDV assessed by MRI at 4 months LVEF and LVEDV MRI at 4 month

48 Primary Endpoint #1 4m) CTO-PCI (n=136) No CTO-PCI (n=144) Difference (95%CI) p LVEF (%) 44 1 (12 2) 44 8 (11 9) -0 8 (-3 6 to 2 1) 0 597

49 Primary Endpoint #2 4m) CTO-PCI (n=136) No CTO-PCI (n=144) Difference (95%CI) p LVEDV (ml) (62 5) (60 3) 2 8 (-11 6 to 17 2) 0 703

50 LVEF Subgroup analyses

51 Conclusions - CTO-PCI within one week after ppci is feasible and safe - Early CTO-PCI : - not associated with higher 4 months - not associated with lower 4 months - In the subgroup analysis CTO-PCI of the LAD - associated with significantly higher 4 months Additional PCI of a CTO located in the LAD may improve LVEF and potentially improved clinical outcome during follow up.

52 The COMPLETE study Inching Closer to a Solution: Sorting Out the Optimal Strategy for STEMI Patients With Multi-Vessel Coronary Artery Disease The COMPLETE study will randomize approximately 4000 STEMI patients to optimal medical therapy with complete revascularization compared with culprit-only PCI.

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55 614 pts from July 2011 to January 2015 with ppci (at 22 sites) were enrolled to either FFR guided Mvessel PCI or culprit only The preliminary data indicates that a high portion of lesions found in the non IRA visually estimated >50% are FFR negative

56 Is it safer to target one only?

57 Is it safer to target one only?

58 Or all of them at once?

59 The multivessel PCI in STEMI - prefferably staged- seems to be safe and effective (not in hard endpoints) More data coming Stay tuned THANK YOU

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