Long term follow-up of 4 treatment strategies in Multivessel Disease (MVD) following Primary Percutaneous Intervention (PPCI) for ST-Elevation Myocardial Infarction (STEMI)

Abstract

Aims: To evaluate the optimal treatment strategy for non-culprit lesions (n-CL) treatment in MVD STEMI patients following primary PCI, we compared clinical outcome of 4 current treatment strategies. Methods: Of 1472 consecutive patients with STEMI referred for PPCI from 2006 to 2010 without prior bypass surgery (CABG), shock or resuscitation, MVD was present in 832 patients (56%). Patients were divided into four groups; one-staged complete revascularization (CR) at PPCI in 61 patients (1-stage PCI; 65{+/-}15 yrs., 80% men), planned staged CR by PCI in 123 patients (2-stage PCI; 60{+/-}11 yrs., 78% men) or by surgery in 123 patients (CABG; 65{+/-}11 yrs., 76% men) and culprit only PCI followed by medical therapy in 532 patients (MT; 65{+/-}13 yrs., 71% men). End-points were MACCE (mortality, re-AMI, repeat revascularization, non-fatal cerebrovascular accidents) and all-cause mortality at long-term follow-up (FU). Results: Patients in the 2-stage PCI group were younger (p<0.001) and had less previous AMI compared to the MT group (p=0.03). At long-term FU (mean 3.4yrs{+/-}1.2yrs) CR strategies showed significantly lower MACCE (HR 0.66; 95% CI 0.49-0.89, p=0.007) and a trend for lower mortality, compared to the MT group. Moreover, 1-stage PCI and CABG were independent predictors for MACCE at long-term follow-up (HR 0.36; 95% CI 0.17-0.77, p=0.008 and HR 0.61; 95% CI 0.38-0.96, p=0.03), whereas only 1-stage PCI showed a trend for lower mortality (HR 0.16; 95% CI 0.02-1.18, p=0.07). Repeat revascularization was more frequent in the 2-stage PCI group (p<0.001). No differences were found at long term FU for re-AMI or cerebrovascular accidents. Conclusion: For patients with STEMI and MVD admitted for PPCI, complete revascularization strategies had better clinical outcome at long-term follow-up. A large prospective randomized trial is needed to confirm our findings and provide tools for the selection of the optimal revascularization strategy in these patients.