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Lee and Kim: Treat or Not to Treat Non-culprit Coronary Artery with Significant Stenosis during Primary Percutaneous Coronary Intervention
In these days, primary percutaneous coronary intervention (PCI) is the mainstay for the treatment of patients with ST-segment elevation myocardial infarction (STEMI). However, STEMI patients are more likely to have multi-vessel disease (MVD) and co-morbidities, often leading to frustrated complications such as stent thrombosis even in the 2nd generation drug-eluting stent (DES) era. In this regard, there has been controversy about the clinical benefit of complete revascularization of the non-infarct-related coronary arteries.
There were early observational studies reporting that revascularization of non-infarct-related artery during the primary PCI leads to worse outcomes in MVD and STEMI patients by increasing in-hospital mortality.1)
Promising clinical randomized trials have been reported in DES era, that favors complete revascularization in MVD and STEMI patients. In the Preventive Angioplasty in Acute Myocardial Infarction (PRAMI) trial2), preventive PCI in non-infarct-related coronary arteries was associated with 65% reduction of cardiovascular death, myocardial infarction (MI) and refractory angina. Complete versus Lesion-only Primary PCI (CvLPRIT) trial3) also demonstrated complete revascularization of non-infarct-related coronary arteries during index admission reduces the composite of death, MI, heart failure, and ischemia-driven revascularization by 55%. Intriguingly, in PRIMULTI trial,4) complete revascularization guided by fractional flow reserve measurements significantly reduced the risk of death, MI, and ischemia-driven revascularization by 44%.
Given these evidences, the American College of Cardiology Foundation/American Heart Association (ACC/AHA) and European Society of Cardiology (ESC) guidelines for non-infarct-related artery revascularization in STEMI patients with MVD were modified from an earlier class III indication into class IIb indication.5)6) However, most of the previous studies have been conducted using bare metal stent or early generation DES. Therefore, little is known about the efficacy of 2nd generation DES in STEMI patients with MVD. The 2nd generation DES is characterized by improved tissue compatibility and lesser risk of stent thrombosis to enhance a healing process; nowadays recognized as a mainstream treatment modality in coronary artery disease.
In this issue of the Korean Circulation Journal, Kwon et al.7) reported the beneficial effect of complete revascularization in STEMI patients with MVD by analyzing the data from the INcheon-Bucheon cohorT of patients undERgoing primary percutaneous coronary intervention for acute ST-ELevation myocardiaL infARction (INTERSTELLAR) registry. They compared the incidence of major adverse cardiac events (MACE) between the MVD patients treated with complete revascularization (n=419) and those treated with culprit-only revascularization (n=286). Complete revascularization of STEMI patients with MVD using the 2nd generation DES was associated with a significant reduction of MACE by 36%. Further, the incidence of cardiovascular death, the hardest endpoint, was also significantly lower in patients treated with complete revascularization (adjusted hazard ratio, 0.57; 95% confidence interval, 0.32–0.97; p=0.03). This finding is consistent with the results of other groups.8)
This study possesses clinical importance since about 25% of patients included for analyses had reduced left ventricular systolic function, which are usually excluded in randomized controlled trials. In conclusion, this study reinforces the usefulness of 2nd generation DES in the treatment of STEMI patients with MVD, thus suggesting the up-to-date treatment strategy. However, previous studies included immediate and staged complete revascularization as a complete revascularization in primary PCI and need to elucidate when immediate complete PCI can be recommended. Furthermore, criteria (anatomical or functional assessment) to intervene for non-culprit lesions should be suggested in future investigations.

Notes

Conflict of Interest The authors have no financial conflicts of interest.

Author Contributions

  • Supervision: Kim JS.

  • Writing - original draft: Lee SJ, Kim JS.

  • Writing - review & editing: Kim JS.

The contents of the report are the author's own views and do not necessarily reflect the views of the Korean Circulation Journal.

References

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4. Engstrøm T, Kelbæk H, Helqvist S, et al. Complete revascularisation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multivessel disease (DANAMI-3—PRIMULTI): an open-label, randomised controlled trial. Lancet. 2015; 386:665–671.
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6. Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC), Steg PG, James SK, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012; 33:2569–2619.
7. Kwon SW, Park SD, Moon J, et al. Complete versus culprit-only revascularization for ST-segment elevation myocardial infarction and multivessel disease in the 2nd generation drug-eluting stent era: data from the INTERSTELLAR registry. Korean Circ J. 2018; 48:989–999.
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8. Kim I, Kim MC, Jeong HC, et al. Optimal timing of percutaneous coronary intervention for nonculprit vessel in patients with ST-segment elevation myocardial infarction and multivessel disease. Korean Circ J. 2017; 47:36–43.
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ORCID iDs

Seung-Jun Lee
https://orcid.org/0000-0002-9201-4818

Jung-Sun Kim
https://orcid.org/0000-0003-2263-3274

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