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Optimal revascularization strategy in non-ST-segment elevation myocardial infarction with multivessel coronary artery disease: staged vs. one-time vs. culprit-only revascularization

Session Revascularisation strategies in ACS

Speaker Associate Professor Min Chul Kim

Congress : ESC Congress 2019

  • Topic : coronary artery disease, acute coronary syndromes, acute cardiac care
  • Sub-topic : Non-ST-Elevation Myocardial Infarction (NSTEMI)
  • Session type : Moderated Posters
  • FP Number : P3127

Authors : M Kim (Gwangju,KR), Y Ahn (Gwangju,KR), MH Jeong (Gwangju,KR), DS Sim (Gwangju,KR), YJ Hong (Gwangju,KR), JH Kim (Gwangju,KR), TH Ahn (Incheon,KR), KB Seung (Seoul,KR), HS Kim (Seoul,KR), HC Gwon (Seoul,KR), SC Chae (Daegu,KR), SH Hur (Daegu,KR), KS Cha (Pusan,KR)

Authors:
M Kim1 , Y Ahn1 , MH Jeong1 , DS Sim1 , YJ Hong1 , JH Kim1 , TH Ahn2 , KB Seung3 , HS Kim4 , HC Gwon5 , SC Chae6 , SH Hur7 , KS Cha8 , 1Chonnam National University Hospital - Gwangju - Korea (Republic of) , 2Gil Hospital - Incheon - Korea (Republic of) , 3Seoul St. Mary's Hospital - Seoul - Korea (Republic of) , 4Seoul National University Hospital - Seoul - Korea (Republic of) , 5Samsung Medical Center - Seoul - Korea (Republic of) , 6Kyungpook National University Hospital - Daegu - Korea (Republic of) , 7Keimyung University Hospital Dongsan Medical Center - Daegu - Korea (Republic of) , 8Pusan National University Hospital - Pusan - Korea (Republic of) ,

Citation:

Background/Introduction: Although optimal revascularization strategy in patients with ST-segment elevation myocardial infarction with multivessel coronary artery disease (MVD) was well established, there are few studies which investigated optimal revascularization strategy in non-ST-segment elevation myocardial infarction (NSTEM) with MVD.

Purpose: We investigated 2-year clinical outcomes according to strategy of revascularization in patients with NSTEMI and MVD.

Methods: Between November 2011 and October 2015, a total of 2474 patients with NSTEMI and MVD who underwent successful percutaneous coronary intervention were analyzed from the Korea Acute Myocardial Infarction Registry-National Institute of Health (staged 308, one-time 1043 and culprit-only 1123 patients). We did not include patients with left main disease and cardiogenic shock. Primary endpoint was major adverse cardiac events (MACE: the composite of cardiac death, myocardial infarction [MI] or target-vessel revascularization [TVR]) during 2-year follow-up (median 737 days [interquartile range 705-764]). We also analyzed the of all-cause mortality, stroke and non-TVR.

Results: Baseline characteristics such as age, gender, and prevalence of atherosclerotic risk factors between multivessel revascularization (MVR; staged or one-time revascularization) and CVR were similar. There was also no difference in symptom to balloon time in 2 groups. MACE occurred in 305 patients (12.3%) during 2-year follow-up. MVR could reduce incidence of MACE (10.2% vs. 14.9%; adjusted hazard ratio [HR] 1.50 for CVR, 95% confidence interval [CI] 1.20-1.88, p <0.001), all-cause death (8.4% vs. 12.1%; adjusted HR 1.45 for CVR, 95% CI 1.13-1.87, p = 0.003) and non-TVR (1,9% vs. 7.0%; adjusted HR 3.99 for CVR, 95% CI 2.55-6.27, p <0.001). There was no difference in incidence of stroke between MVR and CVR. We also analyzed same analysis between staged and one-time revascularization. Complete revascularization was more achieved in one-time revascularization group compared to staged revascularization group (62.0% vs. 76.1%, p <0.001). In multivariate Cox-regression analysis, staged revascularization was not associated with improved clinical outcomes in terms of MACE (HR 0.74, 95% CI 0.50-1.09, p = 0.126), all-cause death (HR 1.07, 95% CI 0.69-1.68, p = 0.759), stroke (HR 1.75, 95% CI 0.68-4.52, p = 0.245) and non-TVR (HR 2.56, 95% CI 0.75-8.68, p = 0.132). Analysis by propensity score matching and inverse probability of treatment weighting did not significantly affect the results.

Conclusions: MVR reduced 2-year adverse cardiac events in patients with NSTEMI and MVD compared to CVR. However, staged revascularization was not superior to one-time revascularization for reducing MACE among NSTEMI patients with MVD who received MVR.

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