STEMI and Multivessel Disease: Medical Therapy Amplifies the Benefit of Complete Myocardial Revascularisation

Aim. To evaluate the results of complete functional endovascular myocardial revascularisation which is performed early after stenting the culprit artery (within 90 days) with third-generation sirolimus-eluting stents in patients treated for acute coronary syndrome (ACS) with ST-segment elevation and multivessel disease. Materials and methods. We analysed the results of a 2-year follow-up treatment period of patients suffering from ACS with ST-segment elevation and multivessel disease who had undergone urgent stenting of culprit artery. Within 90 days after stenting, a complete functional endovascular myocardial revascularisation was performed using third-generation sirolimus-eluting stents. The efficacy and safety of the procedure was evaluated according to the non-inferiority criteria in comparison with the literature data on myocardial revascularisation by coronary artery bypass surgery. Results. In the course of follow-up treatment, 1 lethal myocardial infarction (after 18 months from complete revascularisation) and 2 non-lethal myocardial infarctions were registered. The symptoms of angina returned in 7 patients, 6 of whom had undergone unplanned re-revascularisation within 6 to 12 months following complete revascularisation. The MACCE rate was 0.143 [95% confidence interval: 0.0770; 0.2497]. Conclusion. In patients having ACS with ST-segment elevation and multivessel disease, endovascular myocardial revascularisation performed early after stenting the culprit artery is equivalent to coronary artery bypass surgery in terms of cardiovascular mortality rates, as well as incidence of non-fatal cardiovascular events. However, such an approach underperforms compared to coronary artery bypass surgery in terms of a composite endpoint of MACCE and the number of required re-interventions.

Download Full-text

86 STEMI and multivessel disease: medical therapy amplifies the benefit of complete myocardial revascularization

European Heart Journal Supplements ◽

10.1093/eurheartj/suab140.032 ◽

2021 ◽

Vol 23 (Supplement_G) ◽

Author(s):

Enrico Fabris ◽

Andrea Pezzato ◽

Caterina Gregorio ◽

Giulia Barbati ◽

Luca Falco ◽

...

Keyword(s):

Myocardial Infarction ◽

Propensity Score ◽

Medical Therapy ◽

Beta Blockers ◽

Myocardial Revascularization ◽

Treatment Strategies ◽

Multivessel Disease ◽

Prognostic Impact ◽

Renin Angiotensin ◽

The Impact

Abstract Aims Patients with ST-elevation myocardial infarction (STEMI) with multivessel disease (MVD) may be treated with different revascularization strategies. However, the potential predictors of outcomes on top of different revascularization strategies are poorly studied. This study aimed to evaluate the prognostic impact of two different revascularization strategies and the potential impact of medical therapy. Methods and results Using a propensity score approach, the impact of two treatment strategies was analysed—staged non-culprit revascularization group vs. culprit-lesion-only percutaneous coronary intervention (PCI) group—on a composite outcome of cardiovascular death (CVD), myocardial infarction, and repeated revascularization. Moreover, models were further adjusted for medication at discharge. Among 1385 STEMI patients treated with primary PCI, a subgroup of 433 with MVD was analysed. At the median follow-up of 41 (IQR, 21–65) months, after propensity-score adjustment, the multivariable Cox proportional hazard analysis showed that the staged non-culprit revascularization group was associated with a lower composite endpoint (HR, 0.44; 95% CI, 0.24–0.82; P = 0.01), lower CVD (HR, 0.34; 95% CI, 0.14–0.82; P = 0.02), and lower all-cause death (HR, 0.46; 95% CI, 0.24–0.86; P = 0.02). Use of renin–angiotensin inhibitors was associated with lower CVD (HR, 0.51; 95% CI, 0.27–0.95; P = 0.03), and both renin–angiotensin inhibitors (HR, 0.52; 95% CI, 0.32–0.86; P = 0.01) and beta blockers (HR, 0.48; 95% CI, 0.29–0.79; P = 0.01) were associated with lower all-cause death. Conclusions In a real-word STEMI population with multivessel disease, staged non-culprit revascularization was associated with lower cardiovascular mortality compared with a culprit-only PCI strategy. However, both revascularization and medical therapy played a role in the improvement of mortality outcomes. Medical therapy amplified the benefit of myocardial revascularization.

Download Full-text