Подходы к лечению больных инфарктом миокарда с элевацией сегмента ST при многососудистом поражении коронарного русла
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Material and methods. The manuscript presents hospital and long-term outcomes of 163 consecutive STEMI+MVCD patients treated with different revascularisation strategies. All the patients were divided into three groups. Group 1 (primary percutaneous coronary intervention (PPCI) of the infarct related artery (IRA) only without of staged revascularization in follow-up period (PPCI IRA) (n=70). Group 2 (multivessel (MV) stenting during PPCI) (MV stenting) (n=30). Group 3 (staged PPCI-PCI) (n=63). The study endpoint was the composite of death, myocardial infarction (MI), target vessel revascularisation (TVR).
Results. There was no significant differences between the groups on such endpoints as death, myocardial infarction, target vessel revascularization, stent thrombosis (p>0.05). The cohort of PPCI IRA patients was characterized by the worst outcomes of all the endpoints. The strategy of multiple stenting and staged revascularization demonstrated benefits over PPCI IRA in frequency of combined endpoint (death, myocardial infarction and target vessel revascularization), 10 and 14.3% vs 35.7%, respectively (p<0.05).
Conclusion. Current guidelines for STEMI patients with MV disease suggest a revascularization strategy with staged approach: PPCI IRA and delayed treatment of non-culprit lesions by PCI. In real life a significant proportion of patients do not receiving the second stage of revascularization for various reasons. The strategy of mul tiple stenting for patients without cardiogenic shock in the current recommendations is denied, but in our study obtained comparable results between the group of multiple stenting and staged revascularization and clearly better results in comparison with the group of patients receiving PPCI IRA only, who are encouraged to stage revascularization but did not get it. So our analyses challenge the current guideline recommendations regarding the choice of revascularization strategy in STEMI patients with MV disease.
2. Bolognese L., Cerisano G. Early predictors of left ventricular remodeling after acute myocardial infarction // Am. Heart J. 1999. Vol. 138. P. S79–S83.
3. Cardarelli F., Bellasi A., Ou F. S. et al. Combined impact of age and estimated glomerular filtration rate on in-hospital mortality after percutaneous coronary intervention for acute myocardial infarction (from the American College of Cardiology National Cardiovascular Data Registry) // Am. J. Cardiol. 2009. Vol. 103. P. 766–771.
4. Chen L. Y., Lennon R. J., Grantham J. A. et al. Inhospital and long-term outcomes of multivessel percutaneous coronary revascularization after acute myocardial infarction // Am. J. Cardiol. 2005. Vol. 95. P. 349–354.
5. Corpus R. A., House J. A., Marso S. P. et al. Multivessl percutaneous coronary intervention in patients with multivessel disease and acute myocardial infarction // Am. Heart J. 2004. Vol. 148. P. 493–500.
6. Di Mario C., Mara S., Flavio A. et al. Single vs. multivessel treatment during primary angioplasty: results of the multicentre randomised HEpacoat for cuLPrit or multivessel stenting for Acute Myocardial Infarction (HELP AMI) Study // Int. J. Cardiovasc. Intervent. 2004. Vol. 6, № 3–4. P. 128–133.
7. Freeman R. V., O’Donnell M., Share D. et al. Nephropathy requiring dialysis after percutaneous coronary intervention and the critical role of an adjusted contrast dose // Am. J. Cardiol. 2002. Vol. 90. P. 1068–1073.
8. Gibson C. M., Ryan K. A., Murphy S. A. et al. Impaired coronary blood flow in nonculprit arteries in the setting of acute myocardial infarction. The TIMI Study Group. Thrombolysis in myocardial infarction // J. Am. Coll. Cardiol. 1999. Vol. 34. P. 974–982.
9. Goldstein J. A., Demetriou D., Grines C. L. et al. Multiple complex coronary plaques in patients with acute myocardial infarction // N. Engl. J. Med. 2000. Vol. 343. P. 915–922.
10. Hannan E. L., Samadashvili Z., Walford G. et al. Culprit vessel coronary intervention versus multivessel and staged percutaneous coronary intervention for ST-segment elevation myocardial infarction patients with multivessel disease // JACC Cardiovasc. Interv. 2009. Vol. 3, № 1. P. 22–31.
11. Hanratty C. G., Koyama Y., Rasmussen H. H. et al. Exaggeration of nonculprit stenosis severity during acute myocardial infarction: implications for immediate multivessel revascularization // J. Am. Coll. Cardiol. 2002. Vol. 40. P. 911–916.
12. Hoon L. J., Sik P. H., Chull Ch. Sh. et al. Predictors of six-month major adverse cardiac events in 30-day survivors after acute myocardial infarction (from the Korea Acute Myocardial Infarction Registry) // Am. J. Cardiol. 2009. Vol. 104. P. 182–189.
13. Jan-Henk E. D., Jan P. D., Van't Hof A. W. et al. Non-culprit lesions detected during primary PCI: treat invasively or follow the guidelines? // Eurointervention. 2010. Vol. 5. P. 968–975. 14. Jaski B. E., Cohen J. D., Trausch J. et al.Outcome of urgent percutaneous transluminal coronary angioplasty in acute myocardial infarction: comparison of single-vessel versus multivessel coronary artery disease // Am. Heart J. 1992. Vol. 124. P. 1427–1433.
15. Khattab A. A., Abdel-Wahab M., Rother C. et al. Multi-vessel stenting during primary percutaneous coronary intervention for acute myocardial infarction. A single center experience // Clin. Res. Cardiol. 2008. Vol. 97. P. 32–38.
16. Jeger R. V., Pfisterer M. E. Primary PCI in STEMIdilemmas and controversies: multivessel disease in STEMI patients. Complete versus Culprit Vessel revascularization in acute ST-elevation myocardial infarction // Minerva Cardioangiol. 2010. Vol. 87. P. 28–38.
17. Kong J. A., Chou E. T., Minutello R. M. et al. Safety of single versus multi-vessel coronary artery disease: report from the New-York State Angioplasty Registry // Coron. Artery Dis. 2006. Vol. 17. P. 71–75.
18. Kushner F. G., Mary H., Smith C. S. et al. 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction // J. Am. Coll. Cardiol. 2009. Vol. 54. P. 2205–2241.
19. Ottervanger J. P., Van't Hof A. W., Reifers S. et al. Long-term recovery of left ventricular function after primary angioplasty for acute myocardial infarction // Eur. Heart J. 2001. Vol. 22. P. 785–790.
20. Papamichael N. D., Michalis L. K. Staged percutaneous coronary intervention for multivessel STEMI patients? // Hospital Chronicles. 2010. Suppl. P. 58–59.
21. Parodi G., Memisha G., Valenti R. et al. Five year outcome after primary coronary intervention for acute ST elevation myocardial infarction: results from a single centre experience // Heart. 2005. Vol. 91. P. 1541–1544.
22. Rasoul S., Ottervanger J. P., de Boer M. J. et al. Predictors of 30-day and 1-year mortality after primary percutaneous coronary intervention for STelevation myocardial infarction // Coron. Artery Dis. 2009. Vol. 20. P. 415–421.
23. Roe M. T., Cura F. A., Joski P. S. et al. Initial experience with multivessel percutaneous coronary intervention during mechanical reperfusion for acute myocardial infarction // Am. J. Cardiol. 2001. Vol. 88, № 2. P. 170–173.
24. Saito S., Tanaka S., Hiroe Y. et al. Angioplasty for chronic total occlusion by using tapered-tip guidewires // Catheter Cardiovasc. Interv. 2003. Vol. 59. P. 305–311.
25. Silber S., Albertsson P., Aviles F. F. et al. Guidlines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology // Eur. Heart J. 2005. Vol. 26. P. 804–847.
26. Sorjja P., Gersh B. J., Cox D. A. et al. Impact of multivessel disease on reperfusion success and clinical outcomes in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction // Eur. Heart J. 2007. Vol. 28. P. 1709–1716.
27. Toma M., Buller C. E., Westerhout C. M. et al. Nonculprit coronary artery percutaneous coronary intervention during acute ST-segment elevation myocardial infarction: insights from the APEX-AMI trial // Eur. Heart J. 2010. Vol. 31. P. 1701–1707.
28. Van de Werf F., Ardissino D., Betrio A. et al. Menegement of acute myocardial infarction in patients presenting with ST-segment elevation. The Task Force on the Management of Acute Myocardial Infarction of the European Society of Cardiology // Eur. Heart J. 2003. Vol. 24. P. 28–66.
29. Widimsky P., Jr, Holmes D. R. How to treat patients with ST-elevation acute myocardial infarction and multi-vessel disease? // Eur. Heart J. 2010. doi:10.1093/eurheartj/ehq410.
Abstract
Objective. To compare hospital and long-term outcomes of different revascularisation strategies in STEMI patients with multivessel coronary artery disease (MVCD).Material and methods. The manuscript presents hospital and long-term outcomes of 163 consecutive STEMI+MVCD patients treated with different revascularisation strategies. All the patients were divided into three groups. Group 1 (primary percutaneous coronary intervention (PPCI) of the infarct related artery (IRA) only without of staged revascularization in follow-up period (PPCI IRA) (n=70). Group 2 (multivessel (MV) stenting during PPCI) (MV stenting) (n=30). Group 3 (staged PPCI-PCI) (n=63). The study endpoint was the composite of death, myocardial infarction (MI), target vessel revascularisation (TVR).
Results. There was no significant differences between the groups on such endpoints as death, myocardial infarction, target vessel revascularization, stent thrombosis (p>0.05). The cohort of PPCI IRA patients was characterized by the worst outcomes of all the endpoints. The strategy of multiple stenting and staged revascularization demonstrated benefits over PPCI IRA in frequency of combined endpoint (death, myocardial infarction and target vessel revascularization), 10 and 14.3% vs 35.7%, respectively (p<0.05).
Conclusion. Current guidelines for STEMI patients with MV disease suggest a revascularization strategy with staged approach: PPCI IRA and delayed treatment of non-culprit lesions by PCI. In real life a significant proportion of patients do not receiving the second stage of revascularization for various reasons. The strategy of mul tiple stenting for patients without cardiogenic shock in the current recommendations is denied, but in our study obtained comparable results between the group of multiple stenting and staged revascularization and clearly better results in comparison with the group of patients receiving PPCI IRA only, who are encouraged to stage revascularization but did not get it. So our analyses challenge the current guideline recommendations regarding the choice of revascularization strategy in STEMI patients with MV disease.
References
1. Тарасов Р. С., Ганюков В. И., Барбараш О. Л. и др. Выбор стратегии реваскуляризации у больных инфарктом миокарда с элевацией сегмента ST при многососудистом поражении // Патология кровообр. и кардиохир. 2011. № 2. С. 33–37.2. Bolognese L., Cerisano G. Early predictors of left ventricular remodeling after acute myocardial infarction // Am. Heart J. 1999. Vol. 138. P. S79–S83.
3. Cardarelli F., Bellasi A., Ou F. S. et al. Combined impact of age and estimated glomerular filtration rate on in-hospital mortality after percutaneous coronary intervention for acute myocardial infarction (from the American College of Cardiology National Cardiovascular Data Registry) // Am. J. Cardiol. 2009. Vol. 103. P. 766–771.
4. Chen L. Y., Lennon R. J., Grantham J. A. et al. Inhospital and long-term outcomes of multivessel percutaneous coronary revascularization after acute myocardial infarction // Am. J. Cardiol. 2005. Vol. 95. P. 349–354.
5. Corpus R. A., House J. A., Marso S. P. et al. Multivessl percutaneous coronary intervention in patients with multivessel disease and acute myocardial infarction // Am. Heart J. 2004. Vol. 148. P. 493–500.
6. Di Mario C., Mara S., Flavio A. et al. Single vs. multivessel treatment during primary angioplasty: results of the multicentre randomised HEpacoat for cuLPrit or multivessel stenting for Acute Myocardial Infarction (HELP AMI) Study // Int. J. Cardiovasc. Intervent. 2004. Vol. 6, № 3–4. P. 128–133.
7. Freeman R. V., O’Donnell M., Share D. et al. Nephropathy requiring dialysis after percutaneous coronary intervention and the critical role of an adjusted contrast dose // Am. J. Cardiol. 2002. Vol. 90. P. 1068–1073.
8. Gibson C. M., Ryan K. A., Murphy S. A. et al. Impaired coronary blood flow in nonculprit arteries in the setting of acute myocardial infarction. The TIMI Study Group. Thrombolysis in myocardial infarction // J. Am. Coll. Cardiol. 1999. Vol. 34. P. 974–982.
9. Goldstein J. A., Demetriou D., Grines C. L. et al. Multiple complex coronary plaques in patients with acute myocardial infarction // N. Engl. J. Med. 2000. Vol. 343. P. 915–922.
10. Hannan E. L., Samadashvili Z., Walford G. et al. Culprit vessel coronary intervention versus multivessel and staged percutaneous coronary intervention for ST-segment elevation myocardial infarction patients with multivessel disease // JACC Cardiovasc. Interv. 2009. Vol. 3, № 1. P. 22–31.
11. Hanratty C. G., Koyama Y., Rasmussen H. H. et al. Exaggeration of nonculprit stenosis severity during acute myocardial infarction: implications for immediate multivessel revascularization // J. Am. Coll. Cardiol. 2002. Vol. 40. P. 911–916.
12. Hoon L. J., Sik P. H., Chull Ch. Sh. et al. Predictors of six-month major adverse cardiac events in 30-day survivors after acute myocardial infarction (from the Korea Acute Myocardial Infarction Registry) // Am. J. Cardiol. 2009. Vol. 104. P. 182–189.
13. Jan-Henk E. D., Jan P. D., Van't Hof A. W. et al. Non-culprit lesions detected during primary PCI: treat invasively or follow the guidelines? // Eurointervention. 2010. Vol. 5. P. 968–975. 14. Jaski B. E., Cohen J. D., Trausch J. et al.Outcome of urgent percutaneous transluminal coronary angioplasty in acute myocardial infarction: comparison of single-vessel versus multivessel coronary artery disease // Am. Heart J. 1992. Vol. 124. P. 1427–1433.
15. Khattab A. A., Abdel-Wahab M., Rother C. et al. Multi-vessel stenting during primary percutaneous coronary intervention for acute myocardial infarction. A single center experience // Clin. Res. Cardiol. 2008. Vol. 97. P. 32–38.
16. Jeger R. V., Pfisterer M. E. Primary PCI in STEMIdilemmas and controversies: multivessel disease in STEMI patients. Complete versus Culprit Vessel revascularization in acute ST-elevation myocardial infarction // Minerva Cardioangiol. 2010. Vol. 87. P. 28–38.
17. Kong J. A., Chou E. T., Minutello R. M. et al. Safety of single versus multi-vessel coronary artery disease: report from the New-York State Angioplasty Registry // Coron. Artery Dis. 2006. Vol. 17. P. 71–75.
18. Kushner F. G., Mary H., Smith C. S. et al. 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction // J. Am. Coll. Cardiol. 2009. Vol. 54. P. 2205–2241.
19. Ottervanger J. P., Van't Hof A. W., Reifers S. et al. Long-term recovery of left ventricular function after primary angioplasty for acute myocardial infarction // Eur. Heart J. 2001. Vol. 22. P. 785–790.
20. Papamichael N. D., Michalis L. K. Staged percutaneous coronary intervention for multivessel STEMI patients? // Hospital Chronicles. 2010. Suppl. P. 58–59.
21. Parodi G., Memisha G., Valenti R. et al. Five year outcome after primary coronary intervention for acute ST elevation myocardial infarction: results from a single centre experience // Heart. 2005. Vol. 91. P. 1541–1544.
22. Rasoul S., Ottervanger J. P., de Boer M. J. et al. Predictors of 30-day and 1-year mortality after primary percutaneous coronary intervention for STelevation myocardial infarction // Coron. Artery Dis. 2009. Vol. 20. P. 415–421.
23. Roe M. T., Cura F. A., Joski P. S. et al. Initial experience with multivessel percutaneous coronary intervention during mechanical reperfusion for acute myocardial infarction // Am. J. Cardiol. 2001. Vol. 88, № 2. P. 170–173.
24. Saito S., Tanaka S., Hiroe Y. et al. Angioplasty for chronic total occlusion by using tapered-tip guidewires // Catheter Cardiovasc. Interv. 2003. Vol. 59. P. 305–311.
25. Silber S., Albertsson P., Aviles F. F. et al. Guidlines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology // Eur. Heart J. 2005. Vol. 26. P. 804–847.
26. Sorjja P., Gersh B. J., Cox D. A. et al. Impact of multivessel disease on reperfusion success and clinical outcomes in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction // Eur. Heart J. 2007. Vol. 28. P. 1709–1716.
27. Toma M., Buller C. E., Westerhout C. M. et al. Nonculprit coronary artery percutaneous coronary intervention during acute ST-segment elevation myocardial infarction: insights from the APEX-AMI trial // Eur. Heart J. 2010. Vol. 31. P. 1701–1707.
28. Van de Werf F., Ardissino D., Betrio A. et al. Menegement of acute myocardial infarction in patients presenting with ST-segment elevation. The Task Force on the Management of Acute Myocardial Infarction of the European Society of Cardiology // Eur. Heart J. 2003. Vol. 24. P. 28–66.
29. Widimsky P., Jr, Holmes D. R. How to treat patients with ST-elevation acute myocardial infarction and multi-vessel disease? // Eur. Heart J. 2010. doi:10.1093/eurheartj/ehq410.
