Effect of Multi-Vessel Revascularization During Primary Percutaneous Coronary Intervention on Outcomes of Patients With ST-Segment Elevation Myocardial Infarction.
Complejo Hospitalario Universitario A Coruña, La Coruña, Spain
R. Estevez-Loureiro , A. Rodriguez-Vilela , J. Salgado-Fernandez , E. Barge-Caballero , R. Calviño-Santos , J.M. Vazquez-Rodriguez , G. Aldama-Lopez , P. Piñon-Esteban , N. Vazquez-Gonzalez , A. Castro-Beiras
Background: Multivessel disease has been reported to occur between 40 and 60% of patients with ST-segment elevation myocardial infarction (STEMI) and has been associated to a worse prognosis. Multivessel revascularization offers a myriad of potential advantages as enhance of the collateral blood flow, greater myocardial salvage, the stabilization of other lesions that can be potentially vulnerable, and the achievement of a complete revascularization, factor that is associated with a better prognosis. On the other hand, the prolongation of procedural duration, the hazard of contrast induced nephropathy and the peri-procedural complications can limit the widespread of this practice. To date, very few observational studies have focused in the multivessel revascularization with disparity of results. Whereas ones have observed an increase of adverse cardiovascular events and thus not recommend it, others have shown neutral results. The only randomised conducted trial has yielded inconclusive results. In the current guidelines, the recommendation is to treat only de culprit lesion unless cardiogenic shock has developed, when complete revascularization is strongly advised. Therefore, we sought to investigate if the complete multivessel revascularization during primary percutaneous coronary intervention (PPCI) has an impact on prognosis of patients with STEMI undergoing primary angioplasty.
Methods: We conducted a prospective registry of 618 consecutive patients who underwent PPCI in our centre in the setting of a regional program of STEMI (PROGALIAM) between May 2005 and March 2007. Multi-vessel disease was defined as being the presence of at least one lesion กร70% in a major epicardial vessel or one of its branches other than the infarct related artery (IRA). Patients were excluded when the non-IRA diameter was <2.0 mm or was totally occluded or showed extensive calcification. Patients with significant left main disease were also excluded. Death, re-infarction, new revascularization of any vessel and the combined end-point were regarded as clinical events. Multi-vessel complete revascularization was considered only when it was performed during the index procedure.
Results: During this period 267 patients (43% from overall population, 82% men, age 65กพ12 years) were diagnosed with multi-vessel disease during PPCI for STEMI. From this cohort, 59 patients (22%) underwent completely multi-vessel revascularization (CMR) during the first procedure. Compared with the group that underwent only percutaneous treatment of the IRA, the group of CMR presented an increased use of fluoroscopy (18.5กพ16.8 vs. 14กพ10 min, p=0.012) and contrast (383กพ134 vs. 314กพ147, p=0.001). After a mean follow-up of 17กพ10.5 months, patients in the group of CMR experienced lower rates of death (2% vs. 12%, p=0.032) and new revascularization (0% vs. 10%, p=0.020). A Cox regression analysis to identify factors associated with the combined end-point showed that CMR was an independent variable associated with a better outcome (Hazard ratio [HR] 0.13, CI 95% 0.02-0.95, p=0.045).
Conclusion: In selected groups of patients with STEMI treated with PPCI, CMR is associated with a better outcome.
