Revascularización multivaso o solo de la lesión culpable en pacientes con infarto de miocardio con elevación del segmento ST: análisis de un registro a 8 años / Multivessel versus culprit-only percutaneous coronary intervention in st-segment elevation acute myocardial infarction: analysis of an 8-year registry

Introducción y objetivos: El tratamiento óptimo de los pacientes con enfermedad coronaria multivaso e infarto de miocardio con elevación del segmento ST (IAMCEST) tras una intervención coronaria percutánea (ICP) primaria es motivo de controversia. Con este trabajo se pretende analizar el impacto pronóstico de la ICP multivaso frente a ICP solo de la arteria origen del infarto en pacientes con IAMCEST y enfermedad multivaso en la práctica clínica real. Métodos: Estudio de cohortes retrospectivo que incluyó a 1.499 pacientes consecutivos con diagnóstico de IAMCEST sometidos a ICP primaria entre enero de 2008 y diciembre de 2015. El 40,8% (n = 611) tenía enfermedad coronaria multivaso. Se realizó un análisis mediante puntuación de propensión emparejada, con lo que se obtuvieron 2 grupos de 215 pacientes emparejados según se sometieran a ICP multivaso o solamente de la arteria culpable del infarto. Resultados: Durante el seguimiento (mediana, 2,36 años), tras emparejar por puntuación de propensión, los pacientes sometidos a ICP multivaso tuvieron menos mortalidad (el 5,1 frente al 11,6%; Peto-Peto p = 0,014), revascularización no planeada (el 7,0 frente al 12,6%; Peto-Peto p = 0,043) y eventos cardiovasculares adversos mayores (el 22,0 frente al 30,8%; Peto-Peto p = 0,049). Pese a que no resultó significativa, la tasa de reinfarto fue menor (el 4,2 frente al 6,1%; Peto-Peto p = 0,360). Conclusiones: La estrategia de realizar ICP multivaso en los pacientes con IAMCEST y enfermedad multivaso se asoció a una disminución de la mortalidad, la revascularización no planeada y los eventos cardiovasculares adversos mayores durante el seguimiento de una población de la práctica clínica real (AU)

Introduction and objectives: The optimal treatment of patients with multivessel coronary artery disease and ST-segment elevation acute myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (PCI) is controversial. The aim of this study was to access the prognostic impact of multivessel PCI vs culprit vessel-only PCI in real-world patients with STEMI and multivessel disease. Methods: This was a retrospective cohort study of 1499 patients with STEMI diagnosis who underwent primary PCI between January 2008 and December 2015. About 40.8% (n = 611) patients had multivessel disease. We performed a propensity score matched analysis to obtain 2 groups of 215 patients paired according to whether or not they had undergone multivessel PCI or culprit vessel-only PCI. Results: During follow-up (median, 2.36 years), after propensity score matching, patients who underwent multivessel PCI had lower rates of mortality (5.1% vs 11.6%; Peto-Peto P = .014), unplanned repeat revascularization (7.0% vs 12.6%; Peto-Peto P = .043) and major acute cardiovascular events (22.0% vs 30.8%; Peto-Peto P = .049). These patients also showed a trend to a lower incidence of myocardial infarction (4.2% vs 6.1%; Peto-Peto P = .360). Conclusions: In real-world patients presenting with STEMI and multivessel coronary artery disease, a multivessel PCI strategy was associated with lower rates of mortality, unplanned repeat revascularization, and major acute cardiovascular events (AU)

Multivessel Versus Culprit-only Percutaneous Coronary Intervention in ST-segment Elevation Acute Myocardial Infarction: Analysis of an 8-year Registry.

INTRODUCTION AND OBJECTIVES: The optimal treatment of patients with multivessel coronary artery disease and ST-segment elevation acute myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (PCI) is controversial. The aim of this study was to access the prognostic impact of multivessel PCI vs culprit vessel-only PCI in real-world patients with STEMI and multivessel disease. METHODS: This was a retrospective cohort study of 1499 patients with STEMI diagnosis who underwent primary PCI between January 2008 and December 2015. About 40.8% (n=611) patients had multivessel disease. We performed a propensity score matched analysis to obtain 2 groups of 215 patients paired according to whether or not they had undergone multivessel PCI or culprit vessel-only PCI. RESULTS: During follow-up (median, 2.36 years), after propensity score matching, patients who underwent multivessel PCI had lower rates of mortality (5.1% vs 11.6%; Peto-Peto P=.014), unplanned repeat revascularization (7.0% vs 12.6%; Peto-Peto P=.043) and major acute cardiovascular events (22.0% vs 30.8%; Peto-Peto P=.049). These patients also showed a trend to a lower incidence of myocardial infarction (4.2% vs 6.1%; Peto-Peto P=.360). CONCLUSIONS: In real-world patients presenting with STEMI and multivessel coronary artery disease, a multivessel PCI strategy was associated with lower rates of mortality, unplanned repeat revascularization, and major acute cardiovascular events.

Mortality and cardiovascular morbidity within 30 days of discharge following acute coronary syndrome in a contemporary European cohort of patients: How can early risk prediction be improved? The six-month GRACE risk score.

OBJECTIVES: Given the increasing focus on early mortality and readmission rates among patients with acute coronary syndrome (ACS), this study was designed to evaluate the accuracy of the GRACE risk score for identifying patients at high risk of 30-day post-discharge mortality and cardiovascular readmission. METHODS: This was a retrospective study carried out in a single center with 4229 ACS patients discharged between 2004 and 2010. The study endpoint was the combination of 30-day post-discharge mortality and readmission due to reinfarction, heart failure or stroke. RESULTS: One hundred and fourteen patients had 30-day events: 0.7% mortality, 1% reinfarction, 1.3% heart failure, and 0.2% stroke. After multivariate analysis, the six-month GRACE risk score was associated with an increased risk of 30-day events (HR 1.03, 95% CI 1.02-1.04; p<0.001), demonstrating good discrimination (C-statistic: 0.79 ± 0.02) and optimal fit (Hosmer-Lemeshow p=0.83). The sensitivity and specificity were adequate (78.1% and 63.3%, respectively), and negative predictive value was excellent (99.1%). In separate analyses for each event of interest (all-cause mortality, reinfarction, heart failure and stroke), assessment of the six-month GRACE risk score also demonstrated good discrimination and fit, as well as adequate predictive values. CONCLUSIONS: The six-month GRACE risk score is a useful tool to predict 30-day post-discharge death and early cardiovascular readmission. Clinicians may find it simple to use with the online and mobile app score calculator and applicable to clinical daily practice.

Is 6-month GRACE risk score a useful tool to predict stroke after an acute coronary syndrome?

OBJECTIVES: The risk of stroke after an acute coronary syndrome (ACS) has increased. The aim of this study was to do a comparative validation of the 6-month GRACE (Global Registry of Acute Coronary Events) risk score and CH2DS2VASc risk score to predict the risk of post-ACS ischaemic stroke. METHODS: This was a retrospective study carried out in a single centre with 4229 patients with ACS discharged between 2004 and 2010 (66.9±12.8 years, 27.9% women, 64.2% underwent percutaneous coronary intervention). The primary end point is the occurrence of an ischaemic stroke during follow-up (median 4.6 years, IQR 2.7-7.1 years). RESULTS: 184 (4.4%) patients developed an ischaemic stroke; 153 (83.2%) had sinus rhythm and 31 (16.9%) had atrial fibrillation. Patients with stroke were older, with higher rates of hypertension, diabetes, previous stroke and previous coronary artery disease. The HR for CHA2DS2VASc was 1.36 (95% CI, 1.27 to 1.48, p<0.001) and for GRACE, HR was 1.02(95% CI, 1.01 to 1.03, p<0.001). Both risk scores show adequate discriminative ability (c-index 0.63±0.02 and 0.60±0.02 for CHA2DS2VASc and GRACE, respectively). In the reclassification method there was no difference (Net Reclassification Improvement 1.98%, p=0.69). Comparing moderate-risk/high-risk patients with low-risk patients, both risk scores showed very high negative predictive value (98.5% for CHA2DS2VASc, 98.1% for GRACE). The sensitivity of CHA2DS2VASc score was higher than the GRACE risk score (95.1% vs 87.0%), whereas specificity was lower (14.4% vs 30.2%). CONCLUSIONS: The 6-month GRACE model is a clinical risk score that facilitates the identification of individual patients who are at high risk of ischaemic stroke after ACS discharge.