Revascularization strategies in STEMI and multivessel disease
Authors: Almeida I , Santos H , Miranda H , Santos M , Chin J , Sousa C , Almeida L 
Published: April 2021

Abstract

Funding Acknowledgements
Type of funding sources: None.

OnBehalf
Portuguese Registry of Acute Coronary Syndromes (ProACS)

Introduction
The main treatment for ST elevation myocardial infarction (STEMI) is the reestablishment of coronary flow of infarct related artery. However, 50% of cases present multivessel disease (MVD), negatively affecting mortality. Complete revascularization (CR) is currently advocated since it can reduce major adverse cardiovascular events (MACE).

Objective
Evaluation of revascularization strategy and its prognostic value in a Portuguese cohort of STEMI patients.

Material and methods
Retrospective analysis of patients admitted with STEMI included in the Portuguese Registry of Acute Coronary Syndromes (ProACS) between 2010-19. Patients were divided in two groups regarding revascularization status: complete – group 1; incomplete – group 2. Independent predictors of a composite of all-cause mortality and rehospitalization for cardiovascular causes were assessed by multivariate logistic regression.

Results
3500 patients were included, mean age 65 ± 13 years, 77.7% male. A CR strategy was performed in 21.8%. G1 patients were younger (63 ± 12 vs 66 ± 13, p &lt; 0.001), with less classic cardiovascular risk factors except for smoker status and family history of premature cardiovascular disease, and less previous cardiovascular and kidney disease. They were more hemodynamically stable (Systolic blood pressure 138 ± 30 vs 135 ± 31mmHg, p = 0.019) and have less kidney dysfunction (maximum creatinine 1 ± 0.5 vs 1.2 ± 0.9 mg/dl, p &lt; 0.001) and anemia (hemoglobin 14.3 ± 1.8 vs 13.9 ± 1.9 g/dl, p &lt; 0.001). Inferior STEMI was the most frequent location for both groups, however G1 patients presented lower Killip-Kimball (KK) class (KK class &gt;I 12.7 vs 17.7%, p = 0.001) and BNP value (298 ± 550 vs 453 ± 819pg/ml, p &lt; 0.001) and higher mean left ventricle ejection fraction (LVEF) (52 ± 13 vs 48 ± 12%, p &lt; 0.001). Left anterior descendent (LAD) and right coronary were similarly the most prevalent culprit vessels: the first one in G1 and the second one in G2. 2-vessel disease was more prevalent in G1, having all patients being submitted to percutaneous intervention during hospitalization; and 3-vessel disease in G2 with 0.3% patients being submitted to surgical intervention. G1 patients needed less frequently advanced therapeutic devices and ventilatory support. In-hospital complications were, generally, more frequent in G2 especially HF (21.8% vs 13.9%, p &lt; 0.001) and cardiogenic shock (8.7% vs 6.0%, p 0.005); and mortality was almost twice (3.3% vs. 5.8%, p &lt; 0.001). Global 1-year mortality rate was 6.1% and rehospitalization for cardiovascular causes 13.6%, being CR associated with lower rates (p &lt; 0.001). Predictor factors for this endpoint, evaluated through Cox multivariate regression were IR, tachycardia at admission, KK class &gt; I, involvement of LAD, LVEF &lt; 40%, in-hospital mechanical complication, at discharge medication with digoxin, nitrates and diuretics.

Conclusion
CR was a powerful prognostic biomarker for in-hospital and 1-year all-cause mortality and MACE.