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Cindy L. Grines MD FACC FSCAI Hofstra Northwell School of Medicine Chair, Cardiology
Academic Chief of Cardiology, Northwell Health
North Shore University Hospital, Manhasset NY
Multivessel Disease in AMI
Multivessel disease occurs in 40-60% of patients with STEMI, and 70-80% of patients with shock
It confers higher risk of death, reinfarction, stent thrombosis, lack of compensatory hyperkinesis of the non-infarct zone and development of shock
Multiple culprits may be present due to a systemic inflammatory state
Therefore, treatment of non-culprit vessels may be beneficial
The Case for Not Performing Multi-Vessel
PCI during Infarct Angioplasty
Every PCI for every lesion increases the risk (enhanced
thrombotic and inflammatory state during STEMI)
Longer more complex procedures (contrast
nephropathy, hemodynamic instability)
Additional time, cost, more radiation exposure
Non-culprit lesion severity is often exaggerated during
AMI
Follow up angios showed 20% of “significant” lesions were
now less than 50% narrowed (JACC 2002;40:911-6)
FFR negative in 40% of “significant” lesions (Euro Intervention
2010;5:968)
American Guidelines prior to 2015:
PCI should not be performed in a non-
infarct artery (Class III)
Current Guidelines Class IIb
Eur Heart J. Published online August 26, 2017. doi:10.1093/eurheartj/ehx393
ESC STEMI Guidelines 2017
Primary endpoint: Cardiac death, MI or refractory angina
Wald DS et al. NEJM 2013:on-line
91%
77%
Fre
ed
om
fro
m
Pri
mary
Ou
tco
me (
%)
Months
HR 0.35 (95%CI 0.21-0.58)
P<0.001
No. at Risk
Preventive PCI
No Preventive PCI
0
231
6
234
12 18 24 30 36
168
196
144
166
122
146
96
118
74
89
50
67
0
20
40
60
80
100
PRAMI: “Preventative” PCI of Non-culprit Lsns
after Culprit Lesion Primary PCI in STEMI 465 non-shock pts at 5 UK sites with MVD; after successful primary PCI randomized to
NCL PCI of non-LM DS 50-99% stenoses vs. conservative care
600 pts planned; DSMB stopped trial early after 465 pts enrolled (2008-2013)
Complete revasc
Culprit PCI only
PRAMI Results
Criticisms of the PRAMI study
Small sample size and stopped prematurely
Reported “benefits” are too extreme to be real
Non-infarct vessels did not undergo FFR or
QCA – uncertain of severity
Early reinfarction from the nonculprit vessel
missed since enzymes are already elevated
Limited applicability – “we do not treat 50%
lesions or ignore tight lesions”
(68% acute,
32% staged)
ESC 2014
Cv LPRIT Study:
MVD >70% lesion in Non IRA, >2mm diameter
CvLPRIT
Clinical Outcomes (Primary Endpoint) at 12 months
(Per Protocol Population)
Variable IRA Only Multi-vessel
PCI IRA plus N-
IRA
HR (95% CI) P
MACE 28/138 (20.3) 9/136 (6.6) 0.31 (0.15, 0.65) 0.0011
All-cause
mortality
5/138 (3.6) 1/136 (0.7) 0.20(0.02, 1.73)
0.106
Recurrent MI 4/138 (2.9) 2/136 (1.5) 0.50 (0.09, 2.74) 0.418
Heart failure 7/138
(5.1)
3/136 (2.2) 0.43 (0.11, 1.66) 0.207
Repeat Revasc 12/138 (8.7) 3/136 (2.2) .24 (0.07, 0.85) 0.016
Death/MI 14/146 (9.6) 6/150 (4.0)
ESC 2014
PRAGUE-13 Staged PCI at 3-40 days
Primary Composite Endpoint PCI (n=106) Conservative
(n=108)
Hazard ratio
(95% CI)
p-value
All-cause
mortality/non
fatal
MI/stroke
17 (16.0%) 15 (13.9%) 1.35 (0.66-
2.74)
0.407
All-cause
mortality
6 (5.7%) 7 (6.5%) 0.91 (0.30-
2.70)
0.859
Nonfatal MI 11(10.4%) 8 (7.4%) 1.71 (0.66-
4.41)
0.269
Stroke 0 3 (2.8%)
4 (3.8%) periprocedural infarctions in PCI group with good prognosis
PRAGUE-13
Secondary Endpoints Hazard ratio (95% CI) P-value
Hospitalization for unstable angina 0.52 (0.19-1.40) 0.193
Crossover to another treatment group 0.25 (0.09-0.68)
0.006
Revascularization of non-infarct artery 0.51 (0.24-1.11)
0.089
Cardiovascular mortality 01.34 (0.30-6.01)
0.699
All-cause mortality + nonfatal myocardial infarction + hospitalization for unstable angina
1.03 (0.58-1.84)
0.921
All-cause mortality + nonfatal myocardial infarction + revascularization
0.86 (0.53-1.40)
0.538
Hospitalization for heart failure 0.68 (0.11-4.07)
0.672
Cardiovascularmortality + nonfatal myofcardial infarction + revascularization
0.92 (0.56-1.53)
0.754
No non-infarct lesion progressed to myocardial infarction during follow-up.
Progression of studied non-infarct lesions was very rare
Stenosis
%
No Preventive
PCI
50-74 74
75-94 130
95-99 27
All 231
Primary
outcome event
10
32
11
53
Stenosis Severity and Outcomes
*
* p for trend <0.01
23% (32/130)
Percentage
with event
14% (10/74)
47% (11/27)
23% (53/231)
Should All Lesions be Treated? PRAMI:The tightest lesions have the worst outcomes
Angiography is not ideal to
determine lesion severity. Should
we perform FFR? If so, when?
FFR and complete revascularization performed 2 days post-MI. 31% had negative FFR
Network Meta-analysis of 10 randomized STEMI trials: No difference in Hard Endpoints, Staging is Preferred
Islam Y. Elgendy et al. JACC interventions 2017;10:315-324
American College of Cardiology Foundation
Do you need to wait 2 days to perform
FFR, or can it be done acutely?
COMPARE-ACUTE
COMPARE-ACUTE FFR of Non-IRA is abnormal in 50%
Outcomes based on FFR and management
COMPARE-ACUTE: Primary
Outcome
COMPARE-ACUTE
FFR-guided
Complete (295)
IRA-only
(590)
Hazard
Ratio
P
Value
MACCE 23 (7.8%) 121 (20.5%) 0.35 <0.001
All-Cause Mortality 4 (1.3%) 10 (1.7%) 0.80 0.70
Cardiac Mortality 3 (1.0%) 6 (1.0%)
Myocardial Infarction 7 (2.4%) 28 (4.7%) 0.50 0.10
Revascularization 18 (6.1%) 103 (17.5%) 0.32 <0.001
Stroke 0 4 (0.7%) NA NA
Primary Outcome and Components
Shouldn’t the sickest patients benefit the
most from complete revascularization?
CULPRIT-SHOCK:
A Randomized Trial of Multivessel PCI in Cardiogenic Shock
Holger Thiele, MD
on behalf of the CULPRIT-SHOCK Investigators
All-Cause Mortality
344 237 226 211 203 198 193
341 229 197 179 170 166 165
Culprit lesion only PCI
Immediate multivessel PCI
Number at risk:
0
10
20
30
40
50
60
0 5 10 15 20 25 30
All
-ca
us
e m
ort
ali
ty (
%)
Days after randomization
Immediate multivessel PCI 51.5%
344 237 226 211 203 198 193
341 229 197 179 170 166 165
Culprit lesion only PCI
Immediate multivessel PCI
Number at risk:
0
10
20
30
40
50
60
0 5 10 15 20 25 30
All
-ca
us
e m
ort
ali
ty (
%)
Days after randomization
Culprit lesion only PCI
Immediate multivessel PCI
Relative risk 0.84; 95% confidence interval 0.72-0.98; P=0.03
51.5%
43.3%
Baseline Variable Multivessel PCI Culprit lesion only PCI Relative Risk
(95% CI)
P Value for
Interaction
Sex
Male 148/266 (55.6) 109/257 (42.4) 0.76 (0.64-0.91) 0.11
Female 41/75 (54.7) 48/86 (55.8) 1.02 (0.77-1.35)
Age
<50 years 3/16 (18.8) 6/17 (35.3) 1.88 (0.56-6.29) 0.24
50-75 years 114/226 (50.4) 82/212 (38.7) 0.77 (0.62-0.95)
>75 years 72/99 (72.7) 70/115 (60.1) 0.84 (0.69-1.01)
Diabetes
No 116/218 (53.2) 93/235 (39.6) 0.74 (0.61-0.91) 0.08
Yes 66/116 (56.9) 59/102 (57.8) 1.02 (0.81-1.28)
Hypertension
No 68/129 (52.7) 65/139 (46.8) 0.89 (0.70-1.13) 0.47
Yes 114/205 (55.6) 88/200 (44.0) 0.79 (0.65-0.97)
Type of infarction
NSTEMI 54/97 (55.7) 45/98 (45.9) 0.82 (0.62-1.09) 0.96
STEMI 128/233 (54.9) 108/237 (45.6) 0.83 (0.69-0.99)
STEMI type
Anterior infarction 59/113 (52.2) 57/108 (52.8) 1.01 (0.79-1.30) 0.07
Non-anterior infarction 48/92 (52.2) 34/97 (35.0) 0.67 (0.48-0.94)
Previous infarction
No 154/281 (54.8) 128/279 (45.9) 0.84 (0.71-0.99) 0.83
Yes 28/53 (52.8) 25/60 (41.7) 0.79 (0.53-1.17)
Coronary artery disease
2-vessel disease 64/124 (51.6) 48/122 (39.3) 0.76 (0.58-1.01) 0.56
3-vessel disease 124/215 (57.7) 109/218 (50.0) 0.87 (0.73-1.03)
Chronic total occlusion
No 146/259 (56.4) 131/267 (49.1) 0.87 (0.74-1.02) 0.26
Yes 43/82 (52.4) 27/77 (35.1) 0.67 (0.46-0.97)
0 1 2 3 4 0.25 0.5 1 2 4
Culprit lesion only PCI better Multivessel PCI better
Subgroup Analysis – Primary Endpoint
STEMI with Multivessel Disease
Multivessel disease = worse outcomes
Recent studies suggest complete
revascularization may be beneficial but:
Benefit may be confined to reduction in ischemia
rather than hard endpoints. Harm in shock pts?
Identification of which lesions benefit (likely
abnormal FFR/iFR or tight stenosis) and the
appropriate timing of PCI is unclear
First do no harm: consider staged PCI to reduce
contrast induced renal failure, allow antiplatelets to
become therapeutic and vasomotion of noninfarct
vessels to “normalize” .
Recommended