PCI Strategies for STEMI and Multivessel CAD

Bates ER, Tamis-Holland JE, Bittl JA, O’Gara PT, Levine GN.
PCI Strategies in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Artery Disease. J Am Coll Cardiol 2016;68:1066-1081.

The following are key points to remember about this review on percutaneous coronary intervention (PCI) strategies in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel (MV) coronary artery disease (CAD):

  1. Approximately 50% of patients with STEMI have MV CAD.
  2. There are several potential advantages to performing MV primary PCI.
    • First, acute optimization of myocardial blood supply may increase myocardial salvage in hibernating myocardium or watershed areas of infarction, improving left ventricular ejection fraction, although there are conflicting reports on benefit.
    • Second, MV primary PCI may decrease the compounded risk of vascular complications from the repeat vascular punctures required in a staged procedure.
    • Third, MV primary PCI may decrease hospital length of stay and use fewer resources, increasing cost-effectiveness.
    • Finally, complete revascularization may decrease the risk of a future acute coronary syndrome or revascularization procedure and improve prognosis.
  3. There are also several potential disadvantages to performing MV primary PCI.
    • First, procedure times are prolonged and there is increased radiation exposure.
    • Second, higher contrast media volume increases the risk for contrast nephropathy and acute volume overload, potentially increasing hospital morbidity and mortality.
    • Third, noninfarct artery stenosis severity may be acutely exaggerated as a result of circulating catecholamine-mediated vasoconstriction, and result in PCI of functionally insignificant stenoses.
    • Fourth, the risk of jeopardizing remote viable myocardium during PCI of noninfarct artery stenoses (distal embolization, no-reflow, side branch occlusion, loss of collateral circulation) could result in hemodynamic instability.
    • Finally, there may be increased risk for acute and subacute stent thrombosis in a prothrombotic and proinflammatory state.
  4. The advantage of the staged PCI strategy is more time to appropriately decide on the risks and benefits of additional revascularization, perhaps resulting in better patient selection.
  5. Compared with culprit vessel-only PCI, MV PCI, either at the time of primary PCI or as a staged procedure in selected patients who are hemodynamically stable, appears to be safe and may result in better outcomes.
  6. Whether MV primary PCI or staged PCI is superior remains to be demonstrated.
  7. Indications for noninfarct artery PCI should match elective PCI standards, with routine PCI of intermediate or complex stenoses at the time of primary PCI discouraged.
  8. Until more definitive studies are available, physicians should integrate clinical status and comorbidities, lesion complexity, and clinical judgment to determine the optimal strategy and timing for PCI in patients with STEMI and MV disease.
  9. Demonstration of myocardial ischemia, multidisciplinary evaluation by the Heart Team, and staged PCI (or coronary artery bypass graft surgery) following appropriate use criteria has been the more traditional approach to pursuing MV revascularization.
  10. Additional studies are needed to clarify the indications for and timing of noninfarct artery PCI, and to determine whether major adverse cardiac events are more affected by baseline characteristics than by the additional PCI procedure.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease

Keywords: Acute Coronary Syndrome, Coronary Artery Disease, Catecholamines, Constriction, Pathologic, Coronary Artery Bypass, Myocardial Infarction, Myocardial Ischemia, Myocardium, Percutaneous Coronary Intervention, Primary Prevention, Radiation, Risk Assessment, Stents, Stroke Volume, Thrombosis, Vasoconstriction

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