Suresh Mulukutla MD, FSCAI, and Faisal Latif MD, FSCAI

The Problem

• About 33–50% of patients with STEMI have multivessel CAD (MVCAD).¹
• MVCAD in STEMI is associated with higher rates of early and late mortality and recurrent MI.¹
• In this tip-of-the-month, we outline the data available for reference when interventionalists are confronted with a STEMI patient with MVCAD.

The Previous Guidelines

• 2013 ACC/AHA/SCAI Guidelines recommendation was Class III (Harm) for PCI of non-infarct-related artery PCI in hemodynamically stable STEMI patients.²
• The 2013 guidelines were based on observational studies that were subject to selection bias and small randomized clinical studies. While some studies showed conflicting results, in general, multivessel PCI (MVPCI) was associated with increased mortality compared with culprit-only PCI ³. Comparisons between trials were difficult due to varying study protocols, inclusion criteria, and timing of multivessel PCI.

The Current Guidelines

• 2015 ACC/AHA/SCAI Guidelines have modified the recommendation for PCI of a noninfarct artery. Multivessel PCI may be considered in selected patients with STEMI and multivessel disease who are hemodynamically stable either at the time of primary PCI, or as a planned staged procedure. (Class IIb, Level of Evidence B)⁴
• Clinicians should consider the clinical situation, lesion severity, and contrast volume when selecting a strategy.
• The updated recommendation is supported by emerging evidence.

The Possible Strategies and the Evidence Behind Them

• Primary PCI of Culprit Lesion Only
• Immediate Multivessel PCI at Time of Primary PCI
  • The PRAMI (Preventative Angioplasty in Acute MI) trial showed a significantly lower risk of the primary outcome (composite of cardiac death, nonfatal MI, and refractory angina) with multivessel PCI at the time of primary PCI compared with culprit-only PCI.⁵ The risk of non-fatal MI, and cardiac death or MI was also significantly lower with multivessel PCI.
  • The CvLPRIT (Complete Versus Lesions-Only Primary PCI Trial) showed that MVPCI or as a staged, in-hospital revascularization was associated with lower risk of death, reinfarction, heart failure, and ischemia-driven revascularization.⁶
  • Patients with shock, left main stenosis, chronic total occlusion (CTO), and chronic kidney disease were excluded in both the above trials.
• Primary PCI of Culprit Lesion Followed by Immediate Multivessel PCI of Non-Culprit Lesions Based on Physiologic Assessment (FFR) of Those Lesions
  • The Compare-Acute (Fractional Flow Reserve-Guided Multivessel Angioplasty in Myocardial Infarction) study showed that FFR-guided multivessel PCI following primary PCI was associated with a lower risk of revascularization compared to the culprit-only PCI.⁷
• Primary PCI With Revascularization of Angiographically Severe Lesions During Index Hospitalization (Staged PCI)
  • The DANAMI-3-PRIMULTI (The Third Danish Study of Optimal Acute Treatment of Patients With STEMI: Primary PCI in Multivessel Disease) showed that staged in-hospital multivessel FFR-guided PCI was associated with lower risk of the composite outcome of death, nonfatal MI, or ischemia-driven revascularization compared with culprit-only PCI.⁸
  • The PRAGUE-13 (Primary Angioplasty in Patients Transferred from General Community Hospitals to Specialized PTCA Units with or Without Emergency Thrombolysis-12) showed no difference in outcomes between staged multivessel PCI compared with culprit-only PCI.⁷
• STEMI With Cardiogenic Shock and Multivessel CAD
  • In a 344-patient RCT, patients with MVD and cardiogenic shock who underwent culprit-only PCI (or staged PCI) had a lower 30-day risk of death or need for renal replacement therapy compared to those who underwent multivessel PCI.⁹
  • The KAMIR-NIH registry demonstrated that multivessel PCI was associated with lower risk of all-cause death and non-infarct related artery revascularization among patients with STEMI and shock compared with culprit-only PCI.¹⁰

The Need for More Data!

Additional studies are required to clarify timing of intervention on non-infarct-related arteries (immediate at time of primary PCI, staged in-hospital or staged after hospital discharge), and additional data to determine if there are certain patients for multivessel revascularization in setting of STEMI and cardiogenic shock.

The Bottom Line

Interventionalists should consider the option of multivessel coronary intervention in patients presenting with STEMI and multivessel CAD. Clinical judgment should account for the clinical situation, comorbidities (especially abnormal renal function), lesion complexity, and risk of the procedure. In the setting of cardiogenic shock, it is best to keep coronary revascularization focused on the culprit vessel and assess the appropriateness of concomitant mechanical circulatory support.

References:

1. Park D, Clare RM, Schulte PJ. Extent, location, and clinical significance of non-infarct-related coronary artery disease among patients with ST-elevation myocardial infarction. JAMA 2014;312(19):2019-2027
2. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. J Am Coll Cardiol 2013;61(4):e78-e140.
3. Vlaar PJ, Mahmoud KD, Holmes DR Jr, et al. Culprit vessel only versus multivessel and staged percutaneous coronary intervention for multivessel disease in patients presenting with ST-segment elevation myocardial infarction: a pairwise and network meta-analysis. J Am Coll Cardiol 2011;58:692–703
4. Levine GN, Bates ER, Blankenship JC, et al. 2015 ACC/AHA/SCAI Focused Update on Primary PCI for Patients With STEMI. 2016;133(11):1135-47.
5. Wald DS, Morris JK, Wald NJ, et al. Randomized Trial of Preventive Angioplasty in Myocardial Infarction. N Engl J Med 2013; 369:1115-1123.
6. Gershlick AH, Khan JN, Kelly DJ, et al. Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel disease: the CvLPRIT trial. J Am Coll Cardiol. 2015 Mar 17;65(10):963-72.
7. Smits PA, Abdel-Wahab M, Neumann FJ, et al. Fractional Flow Reserve-Guided Multivessel Angioplasty in Myocardial Infarction. N Engl J Med 2017;376:1234-1244.
8. 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.
9. Hlinomaz O. Multivessel coronary disease diagnosed at the time of primary PCI for STEMI: complete revascularization versus conservative strategy: the PRAGUE 13 trial. Presented at: EuroPCR; May 19, 2015; Paris, France.
10. Thiele H, Akin I, Sandri M, et al. PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock. N Engl J Med 2017; 377:2419-2432
11. Lee JM, Rhee TM, Hahn JY, et al. Multivessel Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction With Cardiogenic Shock. J Am Coll Cardiol 2018 Feb 71(8): 844-856.