Complete vs Culprit-Only Revascularization in Older Patients With Myocardial Infarction With or Without ST-Segment Elevation.

BACKGROUND: The effectiveness of complete revascularization is well established in patients with ST-segment elevation myocardial infarction (STEMI), but it is less investigated in those with non-ST-segment elevation myocardial infarction (NSTEMI). OBJECTIVES: This study aimed to assess whether complete revascularization, compared with culprit-only revascularization, was associated with consistent outcomes in older patients with STEMI and NSTEMI. METHODS: In the FIRE (Functional Assessment in Elderly MI Patients with Multivessel Disease) trial, 1,445 older patients with myocardial infarction (MI) were randomized to culprit-only or physiology-guided complete revascularization, stratified by STEMI (n = 256 culprit-only vs n = 253 complete) and NSTEMI (n = 469 culprit-only vs n = 467 complete). The primary outcome comprised a composite of death, MI, stroke, or revascularization at 1 year. The key secondary outcome included a composite of cardiovascular death or MI at 1 year. RESULTS: In the overall study population, physiology-guided complete revascularization reduced both primary and key secondary outcomes. The primary outcome occurred in 54 (21.1%) STEMI patients randomized to culprit-only vs 41 (16.2%) STEMI patients of the complete group (HR: 0.75; 95% CI: 0.50-1.13) and in 98 (20.9%) NSTEMI patients randomized to culprit-only vs 72 (15.4%) NSTEMI patients of the complete group (HR: 0.71; 95% CI: 0.53-0.97), with negative interaction testing (P for interaction, 0.846). Similarly, no signal of heterogeneity with respect to the initial clinical presentation was observed for the key secondary endpoint (P for interaction, 0.654). CONCLUSIONS: Physiology-guided complete revascularization, compared with culprit-only revascularization, provided consistent benefit across the whole spectrum of patients with MI. (FIRE [Functional Assessment in Elderly MI Patients With Multivessel Disease]; NCT03772743).

Impact of complete versus culprit-only revascularization on major adverse cardiovascular event in diverse subpopulations.

Background: Myocardial infarction management relies on pharmaceuticals and interventions like percutaneous coronary intervention (PCI). While complete PCI has shown noninferiority to culprit-only PCI, its impact on major adverse cardiovascular events (MACE) outcomes in multiple subpopulations has been unknown.Methods: A systematic literature search (from January 2000 to May 2024) identified four relevant randomized controlled trials involving ST-segment elevation myocardial infarction patients. Data analysis employed a random-effects model with inverse variance weighting.Results: MACE risk was significantly lower in males than females undergoing complete PCI compared with culprit-only PCI (hazard ratio: 0.52; 95% CI: 0.39-0.68; p < 0.01; I2 = 53%). Furthermore, complete PCI significantly lowered the risk of MACE outcomes in patients without diabetes and in patients under the 65-year age limit in comparison to culprit-only PCI.Conclusion: Complete PCI reduces MACE risk in male, nondiabetic ST-segment elevation myocardial infarction patients under 65 with multivessel coronary artery disease, necessitating further investigation into outcome differences among different subpopulations.

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Impact of Immediate Versus Staged Complete Revascularization on Short-Term and Long-Term Clinical Outcomes in Patients With Acute Coronary Syndrome and Multivessel Disease: A Systematic Review and Meta-Analysis.

BACKGROUND: In patients with acute coronary syndrome (ACS) and multivessel disease (MVD), complete revascularization (CR) improves prognosis. This meta-analysis, summarizing recent RCTs, contrasts short-term and long-term clinical outcomes between immediate complete revascularization (ICR) and staged complete revascularization (SCR). METHODS: We systematically searched the online database and eight RCTs were involved. The primary outcomes included long-term unplanned ischemia-driven revascularization, re-infarction, combined cardiovascular (CV) death or myocardial infarction (MI), all-cause death, CV death, stroke, and hospitalization for heart failure (HHF). The secondary outcomes were 1-month unplanned ischemia-driven revascularization, re-infarction, all-cause death, and CV death. Safety endpoints included stent thrombosis and major bleeding. RESULTS: Eight RCTs comprising 5198 patients were involved. ICR reduced long-term unplanned ischemia-driven revascularization (RR 0.64, 95% CI 0.51-0.81, p < 0.001), combined CV death or MI (HR 0.51, 95% CI 0.34-0.78, p = 0.002), and re-infarction (RR 0.66,95% CI 0.48 to 0.91, p = 0.012) compared with SCR. ICR also decreased 1-month unplanned ischemia-driven revascularization (RR 0.41, 95% CI: 0.21-0.77, p = 0.006) and re-infarction (RR 0.33, 95% CI:0.15-0.74, p = 0.007) but increased 1-month all-cause death (RR 2.22, 95% CI 1.06-4.65, p = 0.034). CONCLUSION: In ACS patients with MVD, we first found that ICR significantly lowered the risk of both short-term and long-term unplanned ischemia-driven revascularization and re-infarction, as well as the long-term composite outcome of CV death or MI compared with SCR. However, there may be an increase in 1-month all-cause death in the ICR group.

Prognostic value of NT-proBNP and uric acid in acute ST-segment elevation myocardial infarction patients after complete revascularization.

OBJECTIVES: To explore the prognostic value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and uric acid (UA) in acute ST-segment elevation myocardial infarction (STEMI) patients after complete revascularization (CR). METHODS: The clinical and physical data from 125 acute STEMI patients (research group) who underwent CR between December 2017 and December 2020 and 60 healthy individuals (control group) who concurrently underwent physical examinations in the Affiliated Hospital of Guizhou Medical University were retrospectively analyzed in this study. Serum samples were collected from both groups to determine the levels of NT-proBNP and UA. The 3-year follow-up data of acute STEMI patients were collected, which were used to group the patients into a good and a poor prognosis group based on their prognoses to comparatively analyze NT-proBNP and UA levels. Receiver operating characteristic (ROC) curves were drawn to analyze the prognostic value of NT-proBNP and UA in STEMI patients following CR, and survival curves were plotted to observe their influences on patients' 3-year overall survival (OS). Meanwhile, a univariate analysis was conducted to identify factors associated with the 3-year OS of acute STEMI patients after CR. RESULTS: The data showed significantly higher expression levels of serum NT-proBNP and UA in acute STEMI patients than in the controls. Besides, the good prognosis group exhibited markedly lower serum NT-proBNP and UA levels than the poor prognosis group. The areas under the curve (AUCs) of NT-proBNP and UA in predicting the prognosis of acute STEMI patients after CR were all above 0.700, and the AUC of their combined detection reached over 0.800. In addition, high serum NT-proBNP and UA levels were strongly associated with lower 3-year OS rates. As indicated by the univariate analysis, a history of smoking and alcoholism as well as high NT-proBNP and UA levels were closely associated with 3-year OS in acute STEMI patients after CR. CONCLUSIONS: NT-proBNP and UA have promising prognostic value in acute STEMI after CR.

Impact of Stenting Long Lesions on Clinical Outcomes in Patients Presenting With Acute Coronary Syndrome and Multivessel Disease: Data From the BIOVASC Trial.

An increased total stent length (TSL) might be associated with a higher risk of clinical events; however, in patients with multivessel disease (MVD), a considerable TSL is often required. In patients presenting with acute coronary syndrome and MVD, immediate complete revascularization was associated with shorter TSL in the BIOVASC Trial. This is a subanalysis of the BIOVASC trial comparing clinical outcomes in patients with either <60 or ≥60 mm TSL. The primary outcome was a composite of all-cause mortality, myocardial infarction, any unplanned ischemia driven revascularization, or cerebrovascular events at 2 years after the index procedure. A total of 1,525 patients were enrolled in the BIOVASC trial, of whom 855 had a TSL of ≥60 mm (long TSL). No significant difference was established when comparing patients treated with either long or short TSL in terms of the primary outcome at 2-year follow-up, which occurred in 117 patients (13.7%) in the ≥60 mm group and 69 patients (10.3%) in the <60 mm group (adjusted hazard ratio 1.25, 95% confidence interval 0.92 to 1.69, p = 0.16). Furthermore, no significant differences were observed in the secondary end points. In conclusion, in patients with acute coronary syndrome and MVD, long stenting did not show a significant difference in clinical event rate compared with short stenting.

Systematic review and meta-analysis comparing complete versus incomplete or culprit-only revascularization by percutaneous coronary intervention in elderly patients with acute coronary syndrome.

BACKGROUND: Complete revascularization (CR) is favored over culprit-only or incomplete revascularization (IR) for patients with acute coronary syndrome (ACS) and multi-vessel disease (MVD) due to better long-term outcomes. However, the optimal revascularization strategy is currently uncertain in elderly patients, where frailty, polypharmacy, multi-morbidity, inherent bleeding risk and presumed cognitive decline can often burden the decision-making process. METHODS: We searched Medline, PubMed, and Google Scholar from inception to April 2024. The search of databases identified relevant studies that reported the comparative effects of CR and IR in the elderly population undergoing percutaneous coronary intervention (PCI). Data was pooled for individual studies using random-effects models on Comprehensive Meta-Analysis software, with statistical significance set at p < 0.05. RESULTS: The meta-analysis included 14 studies and 62577 patients. CR demonstrated a significant reduction in all-cause mortality [RR: 0.680; 95 % CI: 0.57-0.82; p=<0.001], cardiovascular-related mortality [RR: 0.620; 95 % CI: 0.478-0.805; p=<0.001], and myocardial infarction [RR: 0.675; 95 % CI: 0.553-0.823; p=<0.001] rates. There was no difference between the risk of stroke [RR: 1.044; 95 % CI: 0.733-1.486; p = 0.81], major bleeding [RR: 1.001; 95 % CI: 0.787-1.274; p = 0.991], stent thrombosis [RR: 1.015; 95 % CI: 0.538-1.916; p = 0.936], and contrast-induced acute kidney injury [RR: 1.187; 95 % CI: 0.963-1.464; p = 0.109]. CONCLUSION: The meta-analysis suggests that CR may be a favorable revascularization strategy for elderly patients undergoing PCI, displaying a significant decrease in mortality and repeat myocardial infarction risk.

Predictive utility of residual SYNTAX score for clinical outcomes after successful primary percutaneous coronary intervention.

BACKGROUND: In patients presenting with ST-segment elevation myocardial infarction (STEMI), the prevalence of having concomitant severe non-culprit lesion(s) is ≥40%. While timely primary PCI (pPCI) for the culprit lesion is the standard practice, management of the non-culprit lesions remains unsettled. RESULTS: This prospective multi-center observational study recruited 492 acute STEMI patients who underwent successful pPCI for the culprit lesion. Culprit-only versus complementary non-culprit lesion(s) PCI (either immediate or staged during the same hospital stay) was according to the operator's discretion. Clinical, echocardiographic, and angiographic data were collected and tabulated. The residual SYNTAX score (rSS) was completed by the time of discharge considering the residual lesions after all in-hospital revascularization procedures. Through a minimum follow-up of 12 months, older age, presentation with heart failure Killip class ≥ II, lower estimated glomerular filtration rate (eGFR) on admission, lower left ventricular ejection fraction (LVEF), and higher rSS by discharge were significantly associated with recurrent MACE. In multivariate regression analysis, Killip class ≥ II, LVEF, and rSS were found to be independent predictors for recurrent MACE. In the Receiver Operating Characteristics curve, an rSS of >8 had a sensitivity of 70.1%, and specificity of 75.3% to predict 1-year MACE. CONCLUSIONS: Residual syntax score proved to be an independent predictor for recurrent MACE through the subsequent year post STEMI. Patients with rSS >8 seem to be at the highest risk for adverse events and are likely to be the most deserving for completing revascularization to reduce the disease burden.

The impact of incomplete revascularization on survival in minimal invasive off-pump coronary artery surgery: a propensity score analysis of 1,149 cases.

Background: Minimally invasive concepts are increasingly influential in modern cardiac surgery. This study aimed to evaluate the effect of completeness of revascularization on clinical outcomes and overall survival in minimally invasive, thoracoscopic coronary artery bypass grafting (CABG) surgery. Methods: We retrospectively evaluated a consecutive series of 1,149 patients who underwent minimally invasive off-pump CABG with single, double, or triple-vessel revascularization between 2007 and 2018. Of these patients, 185 (16.1%) had incomplete revascularization (IR) (group I), and 964 (83.9%) had complete revascularization (CR) (group C). We used gradient boosted propensity score estimation to account for possible confounding variables. Results: Median age was 69 years, interquartile range (IQR) 60-76 years, and median EuroSCORE II was 4, IQR 2-7. Of the 1,149 patients, 495 patients suffered from two vessel disease (VD) and 353 presented with three VD. Long-term median follow-up 5.58 (3.27-8.48) years was available for 1,089 patients (94.8%). The incidence of recurrent or persisting angina, myocardial infarction, redo-bypass surgery, and stroke during follow-up did not differ significantly between groups. During follow-up, there were 47 deaths in group I and 172 deaths in group C. The 1-, 3-, 5-, 8-, and 10-year unadjusted survival rates were 94%, 84%, 75%, 62%, and 51% for group I, and 97%, 94%, 88%, 77%, and 72% for group C, respectively (long-rank test P<0.001), favouring CR. Following risk adjustment the long-rank test P value for survival was 0.23. Conclusions: In minimally invasive coronary surgery, IR resulted in decreased long-term survival, but did not achieve statistical significance after risk adjustment. However, IR should only be used in carefully selected cases.

Optional Revascularization Strategies for Patients with ST-Segment Elevation Myocardial Infarction and Multivessel Disease.

Percutaneous coronary intervention is the main strategy of revascularization and has been shown to improve outcomes in some patients with ST-segment elevation myocardial infarction (STEMI). However, multivessel disease (MVD), a common condition in these patients, is associated with worse clinical outcomes compared to single-vessel disease. Despite intervention being a standard treatment for coronary artery disease, optimal strategies and timings for patients with STEMI and MVD remain unclear. Numerous studies and meta-analyses have investigated this topic; however, many current conclusions are based on observational studies. Furthermore, clinical guidelines regarding the management of patients with STEMI and MVD contain conflicting recommendations. Therefore, we aimed to compile relevant studies and newly available evidence-based medicines to explore the most effective approach.

Complete versus culprit-only percutaneous coronary intervention in elderly patients with acute coronary syndrome and multivessel coronary artery disease: A systematic review and meta-analysis.

BACKGROUND: Culprit-only percutaneous coronary intervention (PCI) is commonly performed for acute coronary syndrome (ACS) with multivessel coronary artery disease (MVD) in the elderly. Complete revascularization has been shown to benefit the general population, yet its safety and efficacy in older patients are uncertain. METHODS: Following PRISMA guidelines, we systematically searched PubMed, Embase, and Cochrane databases for randomized controlled trials (RCTs) comparing complete versus culprit-only PCI in patients ≥65 years old with ACS and MVD. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes included myocardial infarction (MI), ischemia-driven revascularization (IDR), all-cause mortality, and cardiovascular mortality. Data were pooled using a random effects model with a restricted maximum likelihood estimator to generate risk ratios (RRs). RESULTS: Five RCTs with 4105 patients aged ≥65 years were included. Compared with culprit-only PCI, complete revascularization reduced MI (RR 0.65; 95 % CI 0.49-0.85; p < 0.01). MACE (RR 0.75; 95 % CI 0.54-1.05; p = 0.09) and IDR (RR 0.41; 95 % CI 0.16-1.04; p = 0.06) were not significantly different between both strategies among those aged ≥65. However, there was a significant reduction in MI (RR 0.69; 95 % CI 0.49-0.96; p-value = 0.03), MACE (RR 0.78; 95 % CI 0.65-0.94; p < 0.01), and IDR (RR 0.60; 95 % CI 0.41-0.89; p < 0.01) in those aged ≥75. CONCLUSIONS: In elderly patients aged ≥65 years with ACS and MVD, a strategy of complete revascularization by PCI reduces MI compared to culprit-only PCI with no significant difference in MACE and IDR. However, complete revascularization reduced MI, MACE, and IDR in those aged ≥75 years suggesting a possible benefit in this age group.

Prognostic value of residual SYNTAX score in patients with coronary artery disease undergoing percutaneous coronary intervention-cohort study.

Residual Syntax Score (RSS) is derived from Syntax Score to quantify the burden of residual coronary artery disease after percutaneous coronary intervention (PCI). As data is limited, we report predictive utility of Residual SYNTAX Score in relation to in hospital and 1 year mortality of the patients undergoing percutaneous coronary intervention (PCI).

Comparison of myocardial perfusion study and invasive hemodynamic measurement of the significance of non-infarct-related residual stenoses in ST elevation myocardial infarction patients.

BACKGROUND: Nearly 50% of ST elevation myocardial infarction (STEMI) patients have multivessel coronary artery disease. The optimal selection of non-culprit lesions for complete revascularization is a matter of current debate. Little is known about the predictive value of myocardial perfusion study (MPS) in this scenario. METHODS: We enrolled 49 STEMI patients (61.5 ± 10.3 years) with at least one major non-culprit lesion (50-90%) other than left main coronary artery lesions. Overall 63 non-infarct- related artery (IRA) stenoses (65.2 ± 11.9%) were recommended for further evaluation using Fractional Flow Reserve (FFR) measurement as is standard in our institution. Prior to FFR, all patients were scheduled for non-invasive MPS using single-photon emission computed tomography (SPECT). Both FFR and MPS were performed 4-8 weeks after STEMI with MPS preceding FFR within no more than 48 hours. An FFR value of ≤0.80 was considered significant and guided the final revascularization strategy. The results of MPS were correlated to FFR as well as to the clinical and angiographic characteristics of both culprit and non-infarct-related lesions. RESULTS: Based on FFR, 30 out of 63 stenoses (47.6%) in 27 patients were considered hemodynamically significant (FFR 0.69 ± 0.08, range 0.51-0.79) compared to residual 33 stenoses considered negative (FFR 0.87 ± 0.04, range 0.81-0.96). The MPS revealed abnormal myocardium (23.6% average, range 5-56%) in 21 patients (42.8%). Among those patients, only 9 showed the evidence of ischemic myocardium (average 10.8%, range 4-18%) with low sensitivity of MPS in predicting positive FFR. Besides that, higher proportion of patients (71.4% vs. 42.9%, P=0.047) with overall lower FFR values (0.73 vs. 0.80, P=0.014, resp.) in non-IRAs as well as higher proportion of patients with more severely compromised flow in IRAs (P=0.048) during STEMI had MPS-detected abnormal myocardium. CONCLUSION: In STEMI patients with multivessel coronary artery disease, we observed rather weak correlation between MPS using SPECT and invasive hemodynamic measurement using FFR in ischemia detection.

Immediate multivessel revascularization after myocardial infarction: change of strategy?

Multivessel coronary artery disease (MVD) is a frequently encountered condition in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) of the culprit vessel. Several studies have demonstrated the benefit of complete coronary revascularization compared with the treatment of the culprit lesion only in patients with STEMI. Based on this evidence, the current European guidelines recommend that in haemodynamically stable patients with STEMI and MVD, routine complete revascularization should be achieved either during the same procedure in concomitance with the treatment of the culprit lesion (immediate multivessel PCI) or with a subsequent intervention within 45 days from the index PCI of the culprit lesion (deferred multivessel PCI). However, the guidelines do not express a preference for immediate vs. delayed multivessel PCI. Therefore, the optimal timing of the treatment of non-culprit lesions in patients with STEMI and haemodynamic stability is still debated and has been evaluated in recent studies that showed the non-inferiority of immediate vs. delayed multivessel PCI. The article discusses the results and clinical implications of these studies on the timing of complete revascularization of non-culprit lesions in haemodynamically stable patients with STEMI.

Impact of Anatomical and Viability-Guided Completeness of Revascularization on Clinical Outcomes in Ischemic Cardiomyopathy.

BACKGROUND: Complete revascularization of coronary artery disease has been linked to improved outcomes in patients with preserved left ventricular (LV) function. OBJECTIVES: This study sought to identify the impact of complete revascularization in patients with severe LV dysfunction. METHODS: Patients enrolled in the REVIVED-BCIS2 (Revascularization for Ischemic Ventricular Dysfunction) trial were eligible if baseline/procedural angiograms and viability studies were available for analysis by independent core laboratories. Anatomical and viability-guided completeness of revascularization were measured by the coronary and myocardial revascularization indices (RIcoro and RImyo), respectively, where RIcoro = (change in British Cardiovascular Intervention Society Jeopardy score [BCIS-JS]) / (baseline BCIS-JS) and RImyo= (number of revascularized viable segments) / (number of viable segments supplied by diseased vessels). The percutaneous coronary intervention (PCI) group was classified as having complete or incomplete revascularization by median RIcoro and RImyo. The primary outcome was death or hospitalization for heart failure. RESULTS: Of 700 randomized patients, 670 were included. The baseline BCIS-JS and SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) scores were 8 (Q1-Q3: 6-10) and 22 (Q1-Q3: 15-29), respectively. In those patients assigned to PCI, median RIcoro and RImyo values were 67% and 85%, respectively. Compared with the group assigned to optimal medical therapy alone, there was no difference in the likelihood of the primary outcome in those patients receiving complete anatomical or viability-guided revascularization (HR: 0.90; 95% CI: 0.62-1.32; and HR: 0.95; 95% CI: 0.66-1.35, respectively). A sensitivity analysis by residual SYNTAX score showed no association with outcome. CONCLUSIONS: In patients with severe LV dysfunction, neither complete anatomical nor viability-guided revascularization was associated with improved event-free survival compared with incomplete revascularization or treatment with medical therapy alone. (Revascularization for Ischemic Ventricular Dysfunction) [REVIVED-BCIS2]; NCT01920048).