A complete versus inducible ischemia-guided revascularization after a culprit-only primary percutaneous coronary intervention in multivessel coronary artery disease – a pilot study

Abstract

Introduction/Objective Revascularization in multivessel coronary artery disease (MVD) in patients with ST elevation myocardial infarction (STEMI) is a matter of debate. We sought to compare outcomes between revascularization strategies based on angiographic lesion severity or inducible ischemia.

Methods In prospective study, first ever STEMI patients with MVD, defined as > 70% stenosis in non-culprit vessel, treated with culprit only primary PCI were randomized to: A. Complete revascularization of all non-culprit significant lesions during initial hospitalization; B. Complete revascularization after 30 days, or C. Revascularization based on non-invasive testing for inducible ischemia. The study explored occurrence of major adverse cardio-cerebral events (MACCE) (cardiac death, repeated MI, cerebrovascular event).

Results The study enrolled 120 patients with door to balloon time within appropriate limits (A 51 ± 26 vs. B 47 ± 33 vs. C 44 ± 29 min, p = 0.604) The patients in group A underwent complete revascularization at 6 [4–7] days after primary PCI, while in the group B it was 35 [32–39] days. In group C, 16/43 (37.2%) patients underwent PCI at 82 [66–147] days after infarction (p < 0.001). The patients were followed for 2.7 ± 0.8 years. The events occurred less frequently in patients that underwent planned complete revascularization compared to those who underwent ischemia testing (7.8 vs. 20.9%, p = 0.040). Kaplan–Meier analysis favored complete delayed revascularization (MACCE A 8.8 vs. B 6.9 vs. C 20.9%, log rank p = 0.041).

Conclusions Planned, angiography guided, complete revascularization after initial event may be favorable strategy compared to single stress test for MVD in STEMI.

Keywords: coronary artery disease; myocardial infarction; stress echocardiography