Approach to Multi Vessel disease with STEMI MANAGEMENT OF ST-ELEVATION MYOCARDIAL INFARCTION

Dr Thomas Alexander

Dr. Thomas Alexander, M.D; D.M; F.A.C.C.Senior Consultant and Interventional Cardiologist

Kovai Medical Centre and Hospital, Coimbatore, India

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 70-80 % 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

Dr Thomas Alexander

Dr Thomas Alexander

Dr Thomas Alexander

Dr Thomas Alexander

NEJM 2013;369:1115

Culprit-only PCI (n=231) – no preventative PCIComplete revascularization (n=234) –

preventative PCIComplete revascularization performed during

index PCI

Dr Thomas Alexander

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)

Randomized following infarct-related artery (IRA)-PCI:

NEJM 2013;369:1115

Dr Thomas Alexander

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

Dr Thomas Alexander

JACC 2015;65:963

296 STEMI patientsRandomized open-label study

Patients with MVD randomized before IRA PCI to : Culprit-only IRA PCI (146 pts) Complete revascularization PCI (150 pts)

At the time of PPCIStaged during index admission

Dr Thomas Alexander

1o outcome: MACE – total mortality/recurrent MI/heartfailure and ischemia- driven revascularization at 12months

JACC 2015;65:963

Dr Thomas Alexander

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

CvLPRIT: has a number of limitations.

Dr Thomas Alexander

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

Dr Thomas Alexander

Dr Thomas Alexander

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

Dr Thomas Alexander

Lancet 2015;386:665

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;10:315-324

Dr Thomas Alexander

Islam Y. Elgendy et al. JCIN 2017;10:315-324

Dr Thomas Alexander

Forest Plot for the Network Meta-Analysis

Islam Y. Elgendy et al. JCIN 2017;10:315-324

Dr Thomas Alexander

Pairwise Meta-Analysis

Islam Y. Elgendy et al. JCIN 2017;10:315-324

Dr Thomas Alexander

Current evidence from randomized trials suggests that the risk of all-cause 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;10:315-324

Conclusions: Randomised Trials

Dr Thomas Alexander

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

Dr Thomas Alexander

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

Dr Thomas Alexander

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

Conclusions: Registry Data

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

Dr Thomas Alexander

< 30% residual stenosis

Excellent IRA PCI Result 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

MVI at Index Procedure

Dr Thomas Alexander

Dr Thomas Alexander

Conclusions

Recent evidence suggests that early treatment of significant non-culpritartery lesions in patients with STEMI, would reduce global ischemic burdenand protect against short and medium-term recurrent ischemic events.

Though, randomised trials show that MVI at Index procedure or stagedyield similar benefits, these enrol relatively low risk patients.

The largest registry data to date shows that the staged MVI has the lowestmortality and repeat revascularisation rate.

Dr Thomas Alexander

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.

Dr Thomas Alexander

Dr Thomas Alexander

Dr Thomas Alexander

Thank You for Your Attention

Dr Thomas Alexander