Approach to Multi Vessel disease with STEMI

Transcription

1 Approach to Multi Vessel disease with STEMI MANAGEMENT OF ST-ELEVATION MYOCARDIAL INFARCTION Dr. Thomas Alexander, M.D; D.M; F.A.C.C. Senior Consultant and Interventional Cardiologist Kovai Medical Centre and Hospital, Coimbatore, India

2 Primary PCI is the standard interventional treatment in STEMI. In patients treated with primary PCI, multivessel disease is present in about 40-50% of hemodynamically stable patients and about % of patients with cardiogenic shock. Two interventional strategies have been used for managing STEMI with MVD. Infarct-related or culprit vessel-only revascularization (CVR), no other diseased vessels are targeted, regardless of their significance. The other strategy is multivessel revascularization (MVR), defined as an intervention of more than one significant stenotic vessel, either adhoc or staged. Multivessel intervention based on Angiography or based on FFR

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6 Culprit-only PCI (n=231) no preventative PCI Complete revascularization (n=234) preventative PCI Complete revascularization performed during index PCI NEJM 2013;369:1115

7 Randomized following infarct-related artery (IRA)-PCI: 465 STEMI patients 1o endpoint: Cardiac death, non-fatal MI or refractory angina 2o endpoints: repeat PCI, non-cardiac death and individual components of 1o endpoint Trial stopped early, mean follow-up 23 months (465 of the anticipated 600 patient enrollment) NEJM 2013;369:1115

8 PRAMI has a number of limitations. The patients in the conservative group did not undergo a staged PCI or even a test for ischemia. PCI of all lesions > 50% without any proof of the hemodynamic significance of the lesion. Premature termination of the trial, which usually means that results between the groups are frozen at the moment of the highest difference. In addition, the differences between multi-vessel PCI and culprit PCI in mortality are greater than between reperfusion and no reperfusion or between primary PCI and fibrinolysis in large clinical trials, which is highly unlikely. NEJM 2013;369:1115

9 296 STEMI patients Randomized open-label study JACC 2015;65:963 Patients with MVD randomized before IRA PCI to : Culprit-only IRA PCI (146 pts) Complete revascularization PCI (150 pts) At the time of PPCI Staged during index admission

10 1o outcome: MACE total mortality/recurrent MI/heart failure and ischemia- driven revascularization at 12 months JACC 2015;65:963

11 CvLPRIT: has a number of limitations. Small study screened 850 patients over 48 months to enroll 296 Trial is underpowered to detect reduction in hard endpoints. The composite endpoint has many components, and none of the components are significant. There are few events in the patients which adds to the uncertainty of the results. The results are in sharp contrast to the results of the much larger COURAGE trial, in which PCI of stable lesions despite proof a ischemia was not associated with an improved outcome compared to optimal medical therapy. JACC 2015;65:963

12 214 STEMI patients Randomized following infarct-related artery (IRA)-PCI: Complete revascularization (n=106) IRA -only PCI (n=108) Complete revascularization performed as a staged procedure Enrollment 48 hrs following onset of symptoms 1o endpoint: All-cause mortality, nonfatal MI, stroke 2o endpoints: cardiac death, all-cause death/nonfatal

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14 627 STEMI patients Randomized following infarct-related artery (IRA)-PCI: Complete FFR-guided revascularization (n=314) IRA -only PCI (n=313) Complete revascularization performed as a staged procedure in hospital 1o endpoint: All-cause mortality, nonfatal MI, ischemia driven revascularization of non IRA lesions Lancet 2015;386:665

15 Lancet 2015;386:665

16 10 Trials with 2285 patients 4 different revascularization strategies were studied - Complete revascularization at Index procedure - Staged Complete IRA at Index and Non culprit treated before discharge - Staged Complete IRA at Index and Non culprit within few weeks of discharge - Culprit only revascularization Pairwise meta-analysis Islam Y. Elgendy et al. JCIN 2017;10:

17 Islam Y. Elgendy et al. JCIN 2017;10:

18 Forest Plot for the Network Meta-Analysis Islam Y. Elgendy et al. JCIN 2017;10:

19 Pairwise Meta-Analysis Islam Y. Elgendy et al. JCIN 2017;10:

20 Conclusions: Randomised Trials Current evidence from randomized trials suggests that the risk of allcause mortality and spontaneous reinfarction is not different among the various revascularization strategies for multivessel disease. Complete revascularization at the index procedure or as a staged procedure (either during the hospitalization or after discharge) was associated with a reduction of MACE due to reduction in urgent revascularization with no difference between these 3 strategies. Islam Y. Elgendy et al. JCIN 2017;10:

21 British Columbia Cardiac Registry - Largest registry to date 6503 STEMI patients with MVD All cause mortality and repeat revascularization at 2 years Three strategies - MV Intervention at Index procedure - MVI - Culprit Vessel Intervention only CVI-O - Culprit vessel Intervention followed by staged Intervention CVI-S M. Bilal Iqbal et al. JCIN 2017;10:11-23

22 M. Bilal Iqbal et al. JCIN 2017;10:11-23

23 Conclusions: Registry Data In patients with STEMI undergoing primary percutaneous coronary intervention, a strategy of CVI-S seems to be associated with lower mortality and repeat revascularization rates. However, MVI may be considered in selected patients and in the setting of non-culprit left anterior descending artery disease M. Bilal Iqbal et al. JCIN 2017;10:11-23

24 Potential Factors that could Influence the decision to do multi-vessel intervention at the Index procedure Number of diseased Vessels Focal or diffuse disease Severity and location of stenosis 50%, CTO Size of Index infarction LV Function Hemodynamic and Electrical Stability Technical complexity Co-morbid conditions Renal function, Diabetes Need for FFR Cost considerations CABG Time of the Day

25 MVI at Index Procedure Excellent IRA PCI Result < 30% residual stenosis TIMI III Epicardial flow TIMI III myocardial blush grade Persistent Ischemic pain Unstable hemodynamics Remote ST-T changes Low contrast volume and short procedure Severity of lesion critical Low anticipated technical difficulty High anticipated success rate and Low rate of anticipated complication

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27 Conclusions Recent evidence suggests that early treatment of significant non-culprit artery lesions in patients with STEMI, would reduce global ischemic burden and protect against short and medium-term recurrent ischemic events. Though, randomised trials show that MVI at Index procedure or staged yield similar benefits, these enrol relatively low risk patients. The largest registry data to date shows that the staged MVI has the lowest mortality and repeat revascularisation rate.

28 Conclusions Benefit of FFR to non culprit vessel intervention, needs to be clarified With the current evidence, non-culprit artery intervention, during the Index procedure, in STEMI is no more deemed as Harmful. At present, in patients with Cardiogenic Shock, complete revascularization during STEMI should be considered only in the presence of multiple, critical stenoses or highly unstable lesions (angiographic signs of possible thrombus or lesion disruption), and if there is persistent ischemia after PCI.

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31 Thank You for Your Attention