Introduction

Multivessel coronary artery disease (MVCAD) is found in up to 40-60% of the patients presenting with ST-elevation myocardial infarction (STEMI) and worsens the prognosis proportional to the extent of coronary artery disease (CAD) severity¹-⁷. Until recently, it was unclear whether patients should receive routine revascularization of angiographic or hemodynamically significant non-culprit lesions or culprit lesion-only revascularization. However, several meta-analyses suggested clinical benefit with percutaneous coronary intervention (PCI) of the non-culprit vessels (NCVs) to achieve multivessel complete revascularization (MVCR) compared with culprit vessel-only PCI⁸-¹¹. Although the most of the studies support the concept of MVCR, the optimal timing of intervention remains uncertain. Our study aims to clarify if there exist benefits of the one-time multivessel revascularization (OTMVR) at the index procedure versus staged in-hospital multivessel revascularization in patients with STEMI and MVCAD.

Material and methods

Exclusion criteria

Patients were excluded if they had left main CAD, coronary artery chronic total occlusions, cardiogenic shock on admission, previous history of PCI or coronary artery bypass grafting, chronic kidney disease with glomerular filtration rate less of 30 mL/min, and missing data (Fig. 1).

Figure 1 Patient selection process. PCI: percutaneous coronary intervention; CAD: coronary artery disease; CTO: chronic total occlusions; CABG: coronary artery bypass grafting; MVCAD: multivessel coronary artery disease; IRA: infarct-related artery; CKD: chronic kidney disease. 

Results

Our study included 634 patients, of which 328 were treated with staged in-hospital revascularization and 306 with OTMVR. Most of our population were men (76.7%), with mean age of 63.3 years. The OTMVR population was older with no differences in comorbidities burden between both groups. Accord to prognostic scores (Killip, GRACE, and TIMI score), there were no differences between groups. Baseline characteristics by groups are found in table 1.

About treatment, the most common reperfusion strategy was primary PCI (55.8%). Pharmacoinvasive strategy was performed in 136 patients (21.3%) and rescue PCI in 144 patients (22.7%). The most common culprit artery was the left anterior descending (LAD) in the OTMVR group (60.1%) and the right coronary artery (RCA) in the staged revascularization group (65.8%). Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score was used to evaluate the severity and complexity of CAD. A higher score was observed in patients in the staged group (20.7 ± 2.0 vs. 17.3 ± 2.1, p < 0.01). Cumulative contrast volume was higher in the staged revascularization group (p = 0.01). The median time to complete revascularization in the staged strategy was 3 days after the index procedure. Full description and comparison of myocardial infarction treatment are found in table 2.

According to the stent complications, we found more under expansion in the OTMVR group and stent thrombosis in the staged group. There were no differences between groups (p = 0.63) about contrast-induced nephropathy even though more contrast volume was used in staged revascularization group. There was no difference in other in-hospital complications such as severe mitral regurgitation, cardiogenic shock, or significant bleeding. In-hospital death was more common in the staged revascularization strategy than in the OTMVR (6.1% vs. 1.3%; p < 0.01), and the leading cause was cardiogenic shock and ventricular arrhythmias.

In the 30-day follow-up, the total cumulative deaths, death for cardiovascular causes, total number of all-cause hospitalizations, cardiovascular hospitalizations, new-onset ACS, and cardiogenic shock were higher in the staged revascularization strategy (p < 0.01). In the 1-year follow-up, the total number of all-cause hospitalizations, cardiovascular hospitalizations, new-onset ACS, total cumulative deaths, and death for cardiovascular causes were also more common in the staged revascularization strategy (p < 0.01). Full description is shown in table 3.

Regression models for mortality prediction (Table 4) showed that the main predictor for in-hospital mortality was cardiogenic shock (p < 0.01). At 30-day and 1-year follow-up, the main predictors of death were cardiogenic shock (p = 0.01), mitral regurgitation (p = 0.01), new-onset ACS (p = 0.01), and acute heart failure on follow-up (p < 0.01). On the other hand, the OTMVR strategy was a predictor for the lower mortality (p < 0.01).

Discussion

The main finding of our study is that after a mean follow-up of 1 year, in patients with STEMI and MVCAD, the OTMVR approach had better outcomes than staged in-hospital complete revascularization. These outcomes included death for all causes, death for cardiovascular causes, cardiovascular complications, and all-cause new hospitalization. The COMPLETE trial is the largest trial about complete revascularization in patients with STEMI and MVCAD. This study confirmed that complete revascularization strategy is the therapy of choice in these patients¹¹. About the best moment of complete revascularization, some studies suggest that OTMVR may be associated with greater mortality risk¹²,¹³, others such as that Hu et al. have been proposed that staged revascularization is the best approach¹⁴. An updated meta-analysis of randomized trials did not demonstrate evidence of a significant interaction between the timing of intervention; that is, there was a consistent treatment effect for complete revascularization versus infarct-related artery PCI, regardless of the timing when complete revascularization was achieved¹⁵. In terms of population, the most of the studies had a clear predominance of the male sex around 70-80% and mean age around 60-64 years old¹¹,¹⁶,¹⁷. Our study showed the same sex ratio and same age. It is essential to mention that our population had a high burden of comorbidities, mainly a higher prevalence of diabetes than other reports¹¹,¹³,¹⁷. Few studies describe the distribution of coronary lesions. In the COMPLETE trial¹¹, RCA was found in a more significant proportion as the IRA. In the study written by Cui et al., LAD is reported as the main culprit vessel in diabetic patients¹⁸. In our study in the OTMVR group, the mainly IRA was proximal LAD, while in the staged revascularization group was RCA. We suggest that this difference can directly impact outcomes because better angiographic success has been observed in PCI on proximal LAD versus proximal circumflex artery/RCA and non-proximal LAD groups¹⁹. It was decided to use the SYNTAX score to evaluate the severity and complexity of CAD²⁰,²¹. Our study showed a higher score in patients in the staged revascularization group which means that these patients had more severe and complex coronary lesions. Accord the reperfusion strategy, primary PCI was carried out in 55.8% of the total population, higher than reported by another Mexican trial²², with a door to wire crossing time according to what is suggested by the current guidelines. Compared to the previous studies¹¹,¹⁶,¹⁸,²³,²⁴, our population had a higher proportion of radial approach and use of drug-eluting stents. We also emphasized the fact that almost 50% of our population underwent an FFR-guided reperfusion strategy. Regarding complications, it is essential to highlight that there was no more contrast-induced nephropathy and no greater incidence of major bleeding between both groups. These results differ from the previous studies¹³, but others have found similar results¹⁵.

Regression analysis showed that the main predictors for mortality were: cardiogenic shock, new-onset ACS, acute heart failure on follow-up, and mitral regurgitation. These factors have been extensively related to mortality in the previous studies²⁵,²⁶. Surprisingly OTMVR strategy proved to be a predictor of the lower mortality. This result differs from the previous studies where this strategy proved to be an independent predictor of mortality¹³, while other studies found a similar hazard ratio for mortality comparing staged PCI with OTMVR among patients who presented with ACS¹⁴.

Conclusions

The complete revascularization strategy should be performed in all patients with STEMI and MVCAD. Regarding the best time to perform treatment of NCV, our results showed that in selected patients, OTMVR at the index procedure could be considered as the best revascularization strategy as it does not generate more complications and demonstrate a decrease in mortality, MACE, and hospital readmissions compared to staged strategy.

Supplementary data

Supplementary data is available at (DOI: 10.24875/ACM.21000375). These data are provided by the corresponding author and published online for the benefit of the reader. The contents of supplementary data are the sole responsibility of the authors.