Key result
Direct stenting in STEMI linked to ~82% lower CMD prevalence versus balloon pre-dilatation.
Why the study?
Coronary microvascular dysfunction is a common complication of STEMI linked to adverse cardiovascular events, but the impact of primary PCI stenting strategies on its prevalence is unclear.
Does direct stenting compared to balloon pre-dilatation reduce the prevalence of coronary microvascular dysfunction in STEMI patients with multivessel disease undergoing primary PCI?
Observational (n=210)
Single-blind
No
Does direct stenting compared to balloon pre-dilatation reduce the prevalence of coronary microvascular dysfunction in STEMI patients with multivessel disease undergoing primary PCI?
Effect estimate: OR 0.184 (95% CI 0.085-0.396)
Absolute Event Rate: 12.24% vs 40.18%
p-value: p=<0.001
In STEMI patients undergoing primary PCI, direct stenting of the culprit lesion is associated with a significantly lower prevalence of coronary microvascular dysfunction at 3 months and a lower incidence of MACE at 12 months compared to balloon pre-dilatation.
Should not yet change stenting practice in STEMI; hypothesis-generating for microvascular benefit pending randomized trials.
Coronary microvascular dysfunction (CMD) is a common complication of ST-segment elevation myocardial infarction (STEMI) and can lead to adverse cardiovascular events. This is a non-randomized, observational, prospective study of STEMI patients with multivessel disease who underwent primary PCI, grouped based on whether they underwent balloon pre-dilatation stenting or direct stenting of the culprit lesion. Coronary physiology measurements were performed 3 months post-PCI including coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) measurements at the culprit vessel. The primary endpoint was the prevalence of CMD at 3 months, defined as IMR ≥ 25 or CFR < 2.0 with a normal fractional flow reserve. Secondary endpoints included major adverse cardiovascular events (MACE) at 12 months. Two hundred ten patients were enrolled; most were men, 125 (59.5%), with a median age of 65 years. One hundred twelve (53.2%) underwent balloon pre-dilatation before stenting, and 98 (46.7%) underwent direct stenting. The prevalence of CMD at 3 months was lower in the direct stenting group than in the balloon pre-dilatation stenting group (12.24% vs. 40.18%; p < 0.001). Aspiration thrombectomy and administration of intracoronary glycoprotein IIb/IIIa inhibitors were associated with lower odds of CMD (OR = 0.175, p = 0.001 and OR = 0.113, p = 0.001, respectively). Notably, MACE in patients who underwent direct stenting was lower than in those who underwent balloon pre-dilatation before stenting (14.29% vs. 26.79%; p = 0.040). In STEMI patients with multivessel disease, direct stenting of the culprit lesion, aspiration thrombectomy and administration of intracoronary glycoprotein IIb/IIIa inhibitors were associated with a lower prevalence of CMD at 3 months and lower incidence of MACE at 12 months compared with balloon pre-dilatation stenting.This trial is registered at https://ichgcp.net/clinical-trials-registry/NCT05406297 .
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Aldujeli et al. (2023) conducted an observational in ST-elevation myocardial infarction (STEMI) with multivessel disease (n=210). Direct stenting vs. Balloon pre-dilatation stenting was evaluated on Prevalence of coronary microvascular dysfunction (CMD) at 3 months (OR 0.184, 95% CI 0.085-0.396, p=<0.001). Direct stenting of the culprit lesion in STEMI patients was associated with a lower prevalence of coronary microvascular dysfunction at 3 months compared to balloon pre-dilatation (12.24% vs 40.18%).
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