Transcript I COSTI DELL'INFARTO MIOCARDICO ACUTO

FLASH DEBATE
PPCI AND MV DISEASE IN STEMI PATIENTS
You have to complete revascularization
with staged PCI in all cases
Leonardo Bolognese
Cardiovascular Department, Arezzo, Italy
Multivessel PCI in STEMI: Treatment Options
Acute Multivessel PCI
Staged non Culprit PCI
Timing (before discharge? After 1, 3,
6months?)
Angiographic or ischemia driven?
Staged CABG
Wait and see
The most savage controversies are
about matters as to which there is
no good evidence either way
Bertrand Russell
PRAMI: Preventive Angioplasty in Myocardial Infarction Trial
Freedom of Cardiac Death, Nonfatal MI or Refractory Angina
Wald DS et al. N Engl J Med 2013; 1° September
Against Angiography-guided Staged
Multivessel Intervention During
Argument # 1
Given that over 50% of pts will not have had
symptoms of angina before the STEMI,
treating N-IRA lesions “just because they are
there” seems inappropriate
Against Angiography-guided Staged
Multivessel Intervention During
Argument # 2
The management of MVD following
successful primary PCI might be
considered analogous to treatment of
stable CAD.
Vulnerable Plaque, Vulnerable Patient
Clinical Course in Patients With Acute MI and
Multiple Complex Plaques
Recurrent Ischemia, MI, and Death @ 1 Year After PCI for AMI
Multiple Complex Plaques (N=100)
Single Complex Plaque (N=153)
Goldstein JA et al. N Engl J Med 2000;343:915-22
PROSPECT: MACE
Stone GW et al. N Engl J Med 2011; 364:226
Impact of Incomplete Angiographic Revascularization
After PCI in ACS: The ACUITY Trial
Rosner GF et al. Circulation. 2012;125:2613-2620
Against Angiography-guided Staged
Multivessel Intervention During
Argument # 3
Current guidelines recommend staged
revascularization only in patients with confirmed
presence of ischemia on noninvasive testing
NEW ESC STEMI GUIDELINES 2012
181 DANAMI
trial 1997 post thrombolysis
216, 232, 233 Hannan
2010; DANAMI 1997, SWISS II
O’Gara et al. JACC 2013; 61:e78–140
The SWISS II Trial
Enrollment from 1991 to 1997
Erne P et al. JAMA. 2007;297:1985-1991
Culprit Vessel vs Multivessel PCI for STEMI
New York State’s PCI Reporting System – 4,024 pts
Hannan EL et al., J Am Coll Cardiol Intv 2010;3:22–31
Culprit Vessel vs Staged Multivessel PCI for STEMI
New York State’s PCI Reporting System – 4,024 pts
Hannan EL et al., J Am Coll Cardiol Intv 2010;3:22–31
Prognostic Impact of Staged Vs “OneTime” Multivessel PCI in AMI
Analysis From the HORIZONS-AMI
Kornowski R et al. J. Am. Coll. Cardiol. 2011;58;704-711
Survival free from MACE (%)
MVD in AMI: Randomized Study for
Three Different Revascularization Strategies
Staged Revasc
Complete Revasc
Culprit Only
p=0.012
Days
Politi L, et al. Heart, 2010;96:662e7
Culprit lesion PCI versus immediate or staged
MV PCI for long-term mortality
Vlaar PJ et al.J Am Coll Cardiol 2011;58:692–703
Against Angiography-guided Staged
Multivessel Intervention During
Argument # 4
Noninvasive imaging can be used to
make these decisions in the setting of
multivessel disease
Myocardial Perfusion Imaging for
Detection of Multivessel CAD
Lima RSL et al. J Am Coll Cardiol 2003;42:64 –70
Pitfalls of Noninvasive Testing in Multivessel Disease
Because they rely on relative flow heterogeneity,
usually identify ischemia caused by the most severe
stenosis.
They may misclassify as normal other vascular zones
supplied by less diseased but still significantly
narrowed arteries.
Microvascular dysfunction in the setting of a nonflow
limiting epicardial coronary artery
Severe endothelial dysfunction can also result in
myocardial defects on SPECT in some patients who
have no significant epicardial stenoses
Fractional Flow Reserve and Myocardial Perfusion
Imaging in Patients With Angiographic Multivessel CAD
Melikian N et al. J Am Coll Cardiol Intv 2010;3:307–14
Plot of FFR Values of
Nonculprit Coronary
Artery Stenoses During
the Acute Phase and at
Follow-Up
Ntalianis A et al. J Am Coll Cardiol Intv
2010;3:1274–81
Fractional Flow Reserve in ACS and Multivessel Disease:
the FAME Study
Sels JM et al. J Am Coll Cardiol Intv 2011;4: 1183–9
CONCLUSIONS
The available evidence on the optimal treatment of MVD
in STEMI pts is scarce, conflicting, with several
methodological biases
The only randomized trial do not address the
question of immediate versus delayed (staged)
preventive PCI
A deferred PCI strategy of non culprit vessels might be
the standard approach in most patients
Surgery is the option of choice in MVD with CTOs, LM
involvement or concomitant severe MR