Immediate and complete revascularisation is required in multivessel disease patients presenting with...

Immediate and complete revascularisation is required in multivessel disease patients

presenting with STEMI- Contra

Mark de Belder

The James Cook University Hospital

Middlesbrough

Debating against Martin:Mission Impossible

Reaction on first meeting (listening to) Martin

• More multi-vessel procedures are being done (in elective patients and non-STEMI ACS)

• Multi-vessel stenting in the era of DES and GP IIb/IIIa inhibitors is delivering outcomes comparable with CABG

Staged vs non-staged procedures in multivessel PCI(predominantly non-emergency)

Nikolsky E et al, Am Heart J 2002;143:1017-26

Staged (n=135) Nonstaged (n=129) P

In-hospital MACE 3 (2.2%) 6 (4.6%) 0.28

1-yr outcome

Q MI 1 (0.7%) 5 (3.9%) 0.09

TLR 23 (17.2%) 28 (21.9%) 0.34

MACE* 35 (26.1%) 46 (35.9%) 0.08

Total LOS (days) 3.56±1.49 2.24±1.89 <0.001

* Staged procedure single independent predictor of lack of MACE at 1-yr (p=0.05)

Multi-vessel disease in AMI

• Multi-vessel disease occurs in 40-65% of patients with AMI

• It confers higher risk in general and higher risk after intervention

• PCI of the IRA is beneficial

• The benefits of treatment of non-culprit vessels are unknown

Kahn JK et al, JACC 1990;16:1089-96Kahn JL et al, Am J Cardiol 1990;66:1045-8Muller DW et al, Am Heart J 1991;121:1042-9

Jaski BE et al, Am Heart J 1992;124:1427-33Shihara M et al, Am J Cardiol 2002;90:932-6Keeley EC, Boura JA, Grines CL. Lancet 2003;361:967-8

The case for performing multi-vessel PCI during infarct angioplasty

• Flow in non-IRA vessels is not normal and is worse in vessels with >50% stenosis

• Slow flow in the non-IRA is associated with reduced non-IRA territory wall thickening, which improves when flow returns to normal

• Enhanced function in the non-IRA territory confers a survival advantage

• Patients often have multiple complex plaques• Coronary plaque instability can be a multi-focal process• These patients have higher event rates• Treatment of these unstable plaques may be beneficial• May be crucial in patients with cardiogenic shock• Simultaneous multi-vessel PCI may reduce vascular access and anti-

coagulant related complications and reduce costs

Grines CL et al. Circ 1989;80:245-53Gibson CM et al, JACC 1999;34:974-82Santoro GM, Buonamici P. Am Heart J 1999;138:126-31Gregorini L et al, Circ 1999;99:482-90

Hochman JS et al, NEJM 1999;341:625-34Goldstein JA et al, NEJM 2000;343:915-22Asakura M et al, JACC 2001;37:1284-8Hanratty CG et al, JACC 2002;40:911-6

“Costs”

• Multi-vessel PCI is more costly to the provider • Staged PCI in the same hospital admission only

attracts a single procedural cost• In the UK, commissioners currently pay a single

price for PCI, regardless of complexity• Complex or staged procedures undoubtedly save

“costs” for commissioners but are very expensive for providers

The case against performing multi-vessel PCI during infarct angioplasty

• Every PCI for every lesion carries a finite risk• Non-culprit lesion severity is often exaggerated during AMI• State of vasoconstriction• Enhanced thrombotic and inflammatory state persists for some time

after an AMI• Longer more complex procedures (contrast nephropathy,

haemodynamic instability)• Additional time, more radiation exposure• Additional cost of the index procedure• Benefits not proven

Fuster V et al. Circulation 1990;82:47-59Shah PK, Forrester JS. Am J Cardiol 1991;68:16-23CStewart DJ et al. JACC 1991;18:38-43Hempel SL et al. Am J Physiol 1993;264:1448-57Ambrose JA, Weinrauch M. Arch Intern Med 1996;156:1382-94Haught WH et al. Am Heart J 1996;132:1-8

Reilly MP et al. Circulation 1997;96:3314-20Bogaty P, et al. Am Heart J 1998;136:884-93Bogaty P et al, Circ 2001;103:3062-8Hanratty CG et al, JACC 2002;40:911-6Barrett TD et al, J Pharmacol Exp Ther 2002;303:1007-13

Risk factors for contrast nephropathy

• Pre-existing renal impairment• Congestive heart failure• Mitral regurgitation• Acute myocardial infarction• Dehydration• Gender (females>males)• Route of administration (I-A > I-V)• Diabetes? (probably dependent on co-existent renal damage)• Elderly? (ditto)• Concurrent use of NSAIDs and other nephrotoxic drugs• Widespread evidence of arterial disease• Hypotension• Hypoalbuminaemia

Which other lesion(s) should you treat?Patients with follow-up angiograms after infarct angioplasty

Hanratty CG et al, JACC 2002;40:911-6

n=48 Infarct angiogram Non-infarct angiogram

P

Nitrate 44 (92%) 20 (42%) <0.01

Statin 11 (23%) 40 (83%) <0.01

ACE-I 14 (29%) 45 (94%) <0.01

Infarct angiogram Non-infarct angiogram

P

Ref diam (mm) 3.1 (0.8) 3.0 (0.8) 0.3

MLD (mm) 1.53 (0.51) 1.78 (0.65) <0.001

% stenosis 49.3 (14.5) 40.4 (16.6%) <0.0001

•Vasoconstriction at time of STEMI more likely an explanation than plaque regression or haemodynamic factors•If immediate revascularisation were attempted on all lesions >50%, this would prompt unnecessary PCI in 1:5 patients

Multivessel PCI in infarct angioplastyRoe MT et al, Am J Cardiol 2001;88:170-3

• 79 cases collected from 8 centres of multi-vessel PCI during infarct angioplasty• 79 control cases of IRA only PCI in patients with multivessel disease (matched for age

and Killip class)• Not confined to shock cases (only 28% Killip IV in both groups)

Multivessel PCI Controls P

GP IIb/IIIa 59.5% 62% NS

Stenting of IRA 70.9% 45.6% <0.001

Core Lab analysis N=58 N=63

Final TIMI 3 84.4% 79.3%

IRA Dissection 3.4% 12.7%

IRA Distal embolisation 1.7% 4.8%

IRA Side branch closure 1.7% 1.6%

Non-IRA Dissection 8.8%

Non-IRA Distal embolisation 3.5%

Non-IRA Side branch closure 1.8%

Multi-vessel PCI in infarct angioplastyRoe MT et al, Am J Cardiol 2001;88:170-3

Rescue PCI Primary PCI

Multivessel PCI (n=11)

Controls (n=18)

P Multivessel PCI (n=68

Controls (n=61)

P

Death 18.2% 16.7% NS 25% 16.4% NS

ReMI 0% 0% 8.8% 1.6% 0.07

CABG 9.1% 11.2% NS 4.4% 0% 0.10

Rpt PCI 9.1% 0% NS 8.8% 11.5% NS

Composite 27.3% 27.8% NS 35.3% 27.9% NS

Stroke 0% 5.6% NS 10.3% 0% 0.01

Multi-vessel PCI in infarct angioplastyCorpus RA et al, Am Heart J 2004;148:493-600

S in g le vesse l d isease(n = 3 1 4 )

P C I o f IR A on ly(n = 3 5 4 )

P C I o f IR A an d n on IR Aw ith in sam e p roced u re

(n = 2 6 )

P C I o f IR A an d n on IR As tag ed w ith in in d ex h osp ita lisa tion

(n = 1 2 6 )

M u lt ivesse l P C I(n = 1 5 2 )

M u lt ivesse l d isease*(n = 5 0 6 )

A M I(n = 8 2 0 )

•Patients undergoing staged procedures at a second admission excluded•*Defined as stenosis 70% of 2 epicardial vessels or their major branches•If stent, clopidogrel 75mg od x at least 4 weeks


1VD

(n=314)

MVD

(n=506)

P

Age 60±13 63±13 0.001

DM 23 (7.3%) 89 (18%) <0.001

HT 121 (39%) 268 (53%) <0.001

Prior MI 24 (7.6%) 104 (20.3%) <0.001

GP IIb/IIIa 93 (30%) 183 (36%) 0.05


1VD (n=314) MVD (n=506) P

30-day outcomes

ReMI 2 (0.6%) 16 (3.2%) 0.02

TVR 4 (1.3%) 37 (7.3%) <0.001

CABG 4 (1.3%) 32 (6.4%) <0.001

Mortality 9 (2.9%) 38 (7.5%) 0.005

MACE 15 (4.8%) 85 (17%) <0.001

1-yr outcomes

ReMI 5 (1.6%) 30 (5.9%) 0.003

TVR 30 (9.6%) 91 (18%) <0.001

CABG 8 (2.6%) 51 (10%) <0.001

Mortality 10 (3.2%) 59 (12%) <0.001

MACE 41 (13%) 159 (31%) <0.001

MV predictors of 1 yr mortality: Renal insufficiency, MV disease, EF≤40%, Age


Patients with multivessel disease

IRA only (n=354) MV PCI (n=152) P

Smoker 238 (67%) 83 (55%) 0.007

GP IIb/IIIa 139 (39%) 44 (29%) 0.03

Stent 307 (87%) 148 (97%) <0.001

30-day outcomes

ReMI 2 (0.6%) 14 (9.2%) <0.001

CABG 28 (8.0%) 4 (2.6%) 0.02

MACE 52 (15%) 33 (22%) 0.053

1-yr outcomes

ReMI 10 (2.8%) 20 (13%) <0.001

TVR 53 (15%) 38 (25%) 0.007

CABG 41 (12%) 10 (6.6%) 0.08

Mortality 42 (12%) 17 (11%) 0.82

MACE 98 (28%) 61 (40%) 0.006

MV analysis for1-yr MACE: MV PCI OR 1.67 (95%CI 1.10-2.54, p=0.01)


Multi-vessel procedures

IRA only (n=354)

MVD Same procedure (n=26)

MVD Staged, in-hospital (n=126)

P

Hospital mortality 20 (5.6%) 5 (19%) 3 (2.4%) 0.003

30-day outcomes

ReMI 2 (0.6%) 0 (0%) 14 (11%) <0.001

TVR 28 (7.9%) 1 (3.8%) 8 (6.3%) 0.66

CABG 28 (8.0%) 1 (3.8%) 2 (2.4%) 0.07

Mortality 23 (6.5%) 5 (19%) 10 (7.9%) 0.06

MACE 52 (14.7%) 6 (23%) 27 (21%) 0.15

1-yr outcomes

ReMI 10 (2.8%) 1 (3.8%) 19 (15%) <0.001

TVR 53 (15%) 3 (12%) 35 (28%) 0.004

CABG 41 (12%) 2 (7.7%) 8 (6.3%) 0.21

Mortality 42 (12%) 5 (19%) 12 (9.5%) 0.36

MACE 98 (28%) 9 (35%) 53 (41%) 0.02


Conclusions

• Patients with MVD have worse outcomes

• Perform IRA PCI only

• Decisions about other vessels should be guided by objective evidence of significant residual ischaemia

• Further trials needed.

Personal experience 2005

72 patients with STEMI

5: No angio 4: Normal or Minor disease6% of 67 with angio 1VD : 25 (37%)

25 1V PCI

2VD : 19 (29%) 3VD: (29%)

4 Med Rx1 ICD

1 dead o/a3 late (med Rx)

1 lysis

1 med Rx12 1V PCI6 MV PCI(2 staged)

2 med Rx2 CABG

11 1V PCI4 MV PCI(2 staged)

67 with angio

7 Med Rx(10%)

48 1V PCI(72%)

6 MV PCISame time

(9%)

4 MV PCIStaged(6%)

2 CABG(3%)

80 year old male in shock

IABP inserted..

75 yr old female, anterior MI

Which vessel?

59 yr old male, anterolateral MI, D1 culprit..but LAD and distal Cx?

Which vessel?

74 yr old male, anterior MIReduced flow in LAD and intermediateBoth acute? 1 chronic?

Next day..

67 year old female, posterior MI

64 yr old male, 6m breathlessness, presents with infero-posterior STEMI

1 week later, wbc and CRP down

Should LAD be done?Asymptomatic, but 1-2mmST depression on ETT

59 yr old male, inferior MI, FINESSE trial

56 yr old male, inferior MI

Very well until 1 year later, non-STEMI

66 yr old man, non-STEMI, 3VD, referred for CABG, then STEMI

3 days later

Conclusions

• Cardiogenic shock is the one situation when it is generally accepted that multi-vessel PCI during infarct angioplasty might be helpful

• Current evidence does not justify a protocol that mandates multi-vessel PCI in this setting

• It may not be unreasonable in individual patients• Potential benefits must be weighed against the undoubted

risks – the strategy overall may be harmful• A large randomised trial using up-to-date techniques is

warranted (but will it ever be done?)

…and finally

• Until then…• Do things because you

should do them, not because you can!

• Or, alternatively…• Just because you’ve got them, don’t let them cloud your clinical judgement. And keep them to yourself!

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