Department of Cardiology, Hôpital Européen Georges Pompidou, AP-HP, 75015 Paris, France; Université de Paris, 75006 Paris, France.
Clinique St. Martin, 14000 Caen, France.
Arch Cardiovasc Dis. 2022 Oct;115(10):496-504. doi: 10.1016/j.acvd.2022.05.011. Epub 2022 Sep 2.
In patients with ST-segment elevation myocardial infarction and multivessel disease, percutaneous coronary intervention for non-culprit lesions is superior to treatment of the culprit lesion alone. The optimal timing for non-infarct-related artery revascularization - immediate versus staged - has not been investigated adequately.
We aimed to assess clinical outcomes at 1 year in patients with ST-segment elevation myocardial infarction with multivessel disease using immediate versus staged non-infarct-related artery revascularization.
Outcomes were analysed in patients from the randomized FLOWER-MI trial, in whom, after successful primary percutaneous coronary intervention, non-culprit lesions were assessed using fractional flow reserve or angiography during the index procedure or during a staged procedure during the initial hospital stay, ≤5 days after the index procedure. The primary outcome was a composite of all-cause death, non-fatal myocardial infarction and unplanned hospitalization with urgent revascularization at 1year.
Among 1171 patients enrolled in this study, 1119 (96.2%) had complete revascularization performed during a staged procedure, and 44 (3.8%) at the time of primary percutaneous coronary intervention. During follow-up, a primary outcome event occurred in one of the patients (2.3%) with an immediate strategy and in 55 patients (4.9%) with a staged strategy (adjusted hazard ratio 1.44, 95% confidence interval 0.39-12.69; P=0.64).
Staged non-infarct-related artery complete revascularization was the strategy preferred by investigators in practice in patients with ST-segment elevation myocardial infarction with multivessel disease. This strategy was not superior to immediate revascularization, which, in the context of this trial, was used in a small proportion of patients. Further randomized studies are needed to confirm these observational findings.
在 ST 段抬高型心肌梗死合并多支血管病变患者中，非罪犯病变的经皮冠状动脉介入治疗优于单纯治疗罪犯病变。非梗死相关动脉血运重建的最佳时机——即刻与分期——尚未得到充分研究。
我们旨在评估 ST 段抬高型心肌梗死合并多支血管病变患者即刻与分期非梗死相关动脉血运重建的 1 年临床结局。
分析来自随机 FLOWER-MI 试验的患者结局，在这些患者中，在成功进行了直接经皮冠状动脉介入治疗后，在指数操作期间或指数操作后≤5 天的初始住院期间，使用血流储备分数或血管造影术评估非罪犯病变。主要结局是 1 年内全因死亡、非致死性心肌梗死和计划外住院并紧急血运重建的复合终点。
在这项研究中，共纳入 1171 例患者，其中 1119 例（96.2%）在分期操作期间完成了完全血运重建，44 例（3.8%）在直接经皮冠状动脉介入治疗时完成。在随访期间，即刻策略组有 1 例患者（2.3%）和分期策略组有 55 例患者（4.9%）发生了主要结局事件（调整后的危险比 1.44，95%置信区间 0.39-12.69；P=0.64）。
分期非梗死相关动脉完全血运重建是研究中 ST 段抬高型心肌梗死合并多支血管病变患者的首选策略。与即刻血运重建相比，这种策略并不占优势，在本试验中，只有一小部分患者接受了即刻血运重建。需要进一步的随机研究来证实这些观察性发现。
