June 1, 2019Journal of Cardiovascular EmergenciesOpen Access

Impact of Multivessel Coronary Artery Disease on Long Term Prognosis in Patients with ST-segment Elevation Myocardial Infarction

Q: What are the key findings of this study?

In STEMI patients treated with primary PCI, the presence of multivessel coronary artery disease independently increased the risk of 6-year cardiovascular mortality compared to single-vessel disease (HR 1.55).

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: ST-segment elevation myocardial infarction (STEMI) (n=3115). Intervention: Multivessel coronary artery disease (MVD) vs. Single-vessel coronary artery disease (No MVD). Primary outcome: 6-year cardiovascular mortality (HR 1.55, 95% CI 1.11-2.06, p=0.041).

Q: What does this research mean for the field?

In STEMI patients treated with primary PCI, multivessel coronary artery disease independently increases the risk of 6-year cardiovascular mortality compared to single-vessel disease. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

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Key result

Multivessel disease in post-PCI STEMI links to ~55% greater 6-year CV mortality versus single-vessel disease.

HR 1.55
95% CI 1.11-2.06
P=0.041
n=3,115

Why the study?

Many STEMI patients have multivessel disease and face high risk for recurrent cardiac events, but the impact of MVD on long-term cardiovascular mortality after pPCI required evaluation.

Does the presence of multivessel coronary artery disease increase long-term cardiovascular mortality in STEMI patients treated with primary PCI?

Study Design

Type

Cohort (n=3,115)

Multicenter

Structured PICO

Does the presence of multivessel coronary artery disease increase long-term cardiovascular mortality in STEMI patients treated with primary PCI?

Population

3,115 consecutive adult patients with STEMI treated with primary PCI, excluding those with cardiogenic shock, followed for 6 years.

Exposure

Presence of multivessel coronary artery disease (MVD), defined as stenosis greater than 50% by visual assessment in more than one major coronary artery.

Comparator

Single-vessel disease (no MVD).

Outcome

6-year cardiovascular mortality (defined as any death from cardiovascular reason including myocardial reinfarction, low-output heart failure, and sudden death).hard clinical

Main Result

Hazard Ratio: 1.55 (95% CI 1.11–2.06)

Absolute Event Rate: 10.4% vs 4.6%

p-value: p=0.041

In STEMI patients undergoing primary PCI, the presence of multivessel disease is an independent predictor of higher 6-year cardiovascular mortality despite early revascularization of non-infarct-related arteries.

Limitations

Observational, single-center study design limits causal inference.
Decision and timing of non-culprit lesion revascularization were not standardized.
MVD assessment was based only on visual angiographic analysis without functional evaluation like fractional flow reserve.
Predominant use of bare metal stents and clopidogrel, without newer antithrombotic drugs like ticagrelor.
Exclusion of patients with cardiogenic shock limits generalizability to that high-risk subgroup.

Implication

MVD identifies higher long-term CV mortality risk after pPCI in STEMI; leaves open whether targeted strategies improve outcomes.

Abstract

Background: A significant proportion of patients with ST-segment elevation myocardial infarction (STEMI) have multivessel coronary artery disease (MVD), and they are at high risk for recurrent cardiac events. The aim of the present study was to analyze the impact of MVD on long-term cardiovascular mortality in STEMI patients treated with primary percutaneous coronary intervention (pPCI). Method: This study included 3,115 consecutive STEMI patients hospitalized in the Coronary Care Unit of the Clinical Centre of Serbia, between November 2005 and January 2012. Patients were divided in two groups: MVD and no MVD. MVD disease was defined as stenosis greater than 50% by visual assessment in more than one major coronary artery. Primary PCI was limited to the infarct-related artery (IRA). Cardiovascular mortality was defined as any death from cardiovascular reason (myocardial reinfarction, low-output heart failure, and sudden death). Patients presenting with cardiogenic shock were excluded. Patients were followed-up for 6 years after enrollment. Results: Among 3,115 analyzed patients, 1,352 (43.4%) patients had no MVD and 1,763 (56.6%) had MVD; among patients with MVD, 926 (52.6%) had two-vessel disease and 837 (47.4%) had three-vessel disease. Compared with patients with single-vessel disease, patients with MVD were older, had longer pain duration, and presented more often with heart failure; they were more likely to have previous coronary artery disease, diabetes, hypertension, and chronic kidney disease; post-procedural flow TIMI <3 was more frequently observed in patients with MVD than in patients with no MVD (5.9% vs. 3.1%, p <0.001). Patients with MVD had lower left ventricular ejection fraction than patients with single-vessel disease: 45% (interquartile range [IQR] 40¬–55%) vs. 50% (IQR 43–55%), p <0.001. Revascularization of non-IRA lesions was performed at index hospitalization in 1,075 (61%) patients, and in 602 (34.1%) patients revascularization was performed in the first few months after pPCI (median 1.5 months, IQR 1–2.5 months); coronary artery bypass grafting was performed in 291 (18.4%) patients and PCI (with stent implantation) in 1,368 (81.6%) patients. Six-year cardiovascular mortality was significantly higher in patients with MVD than in patients with single-vessel disease (10.4% vs. 4.6%, p <0.001). In multivariate Cox regression analysis, MVD remained an independent predictor for 6-year cardiovascular mortality (HR 1.55, 95% CI 1.11–2.06, p = 0.041). Conclusion: In STEMI patients treated with pPCI, the presence of MVD remained an independent predictor for higher long-term cardiovascular mortality despite early revascularization of the remaining stenosis in non-IRA.

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Cite This Study

Savić et al. (2019) conducted a cohort in ST-segment elevation myocardial infarction (STEMI) (n=3,115). Multivessel coronary artery disease (MVD) vs. Single-vessel coronary artery disease (No MVD) was evaluated on 6-year cardiovascular mortality (HR 1.55, 95% CI 1.11-2.06, p=0.041). In STEMI patients treated with primary PCI, the presence of multivessel coronary artery disease independently increased the risk of 6-year cardiovascular mortality compared to single-vessel disease (HR 1.55).

synapsesocial.com/papers/6aa83cc6f592fc864c8ac736 https://doi.org/10.2478/jce-2019-0006