TARGET VESSEL PCI VS MULTIVESSEL PCI IN PAMI.pptx

presentatio

1. Cath meet DR.S.SIVA PRASAD DrNB CARDIOLOGY

2. A 70Y OLD FEMALE CAME TO ER WITH HISTORY OF SOB FROM 12:30PM 7/12/24 a/ i retrosternal discomfort,nausea ,profuse sweating,& belching. PAST HISTORY- underwent CAG 10yrs back for sob. Result was mild cad RISK FACTORS DIABETES-8 YR on regular medication

3. GENERAL PHYSICAL EXAMINATION conscious coherent Pulse-66/mt regular,normal volume B.P-130/80 SPO2-99% in room air SYSTEMIC EXAMINATION CVS-S1,S2 heard R.S-basal creps present. CVS,ABD-NAD

4. ECG

5. ECHO-NORMAL CARDIAC CHAMBERS RWMA PRESENT.INFERIO SEPTAL SEGMENT HYPOKINETIC MILD LV SYSTOLIC DYSFUNCTION EF -45-50% MILD MR NO PE,PAH INTACT SEPTAE

6. DIAGNOSIS-CAD,ACS STEMI,PWMI,KILLIP CLASS II,CARDIAC FAILURE,SR DM

7. CULPRIT VESSEL PCI VS MULTIVESSEL PCI—WHICH IS RECOMMENDED WHAT IS STANDARD OF CARE IN STEMI ?-IT IS PCI OF iRA (INFARCT RELATED ARTERY)WITH IN RECOMMEND WINDOW PERIOD MULTIVESSEL DISEASE- DEFINED AS >50% IN ATLEAST ONE NON-CULPRIT ARTERY. AFFECTS 40-50% OF AMI. NEGATIVELY IMPACT SHORT AND LONG TERM OUTCOME

8. ONE CAN PERFORM -ONLY CULPRIT VESSEL PCI OR MULTIVESSEL PCI AT SAME TIME - CULPRIT VESSEL PCI FOLLOWED BY NON-CULPRIT VESSEL PCI AT SAME HOSPITALISATION -OR NON-CULPRIT VESSEL PCI AFTER DISCHARGE FROM HOSPITAL.

9. DECISION TO PERFORM NON-CULPRIT PCI CAN BE BASED ON - SYMPTOMS -MYOCARDIAL PERFUSION SCAN STUDIES - FFR

10. WHY WE SHOULD PERFORM MULTIVESSEL PCI -FLOW IN IRA IS NOT NORMAL AND WORSE IN VESSELS >50% STENOSIS -ENHANCED FUNCTION IN NON-IRA TERRITORY CONFERS SURVIVAL BENEFIT -PATIENTS OFTEN HAVE MULTIPLE COMPLEX AND UNSTABLE PLAQUES -PT’S HAVE HIGH EVENT RATES -CRUCIAL IN CARDIOGENIC SHOCK PATIENTS

11. TRIALS PRAMI TRIAL PRIMARY END POINTS ARE -DEATH FROM CARDIAC CAUSE -NONFATAL MI -REFRACTORY ANGINA

12. AT 23 MONTHS THERE WAS ARR OF 14% IN PT’S WHO UNDER WENT PREVENTIVE PCI IT DIDN’T ANSWER WHEN TO PERFORM COMPLETE REVASCULARIZATION STUDY DONE B/N 2008 TO 2013, at five centers in the United Kingdom PUBLISHED IN  September 19, 2013  

13. CvLPRIT TRAIL- PUBLISHED IN 16-12-2019 296 patients in 7 U.K. centers I n-hospital complete revascularization (n = 150) or IRA-only revascularization (n = 146). Complete revascularization was performed either at the time of P-PCI or before hospital discharge

14.  The primary endpoint was a composite of all-cause death, recurrent myocardial infarction (MI), heart failure, and ischemia-driven revascularization within 12 months. The primary endpoint occurred in 10.0% of the complete vs 21.2% in the IRA-only revascularization group (hazard ratio: 0.45; 95% confidence interval: 0.24 to 0.84; p = 0.009). A trend toward benefit was seen early after complete revascularization (p = 0.055 at 30 days).

15. DANAMI-3 TRIAL-PUBLISHED IN 2015 ENROLLED 627 PT’S 330 CULPRIT ONLY PCI VS 314 FFR GUIDED COMPLETE REVASCULARIZATION PRIMARY END POINT-ALL CAUSE MORTALITY,NONFATAL MI,ISCHEMIA DRIVEN REVASCULARIZATION COMPLETE REVASCULARIZATION PT’S HAD LOWER ISCHEMIA DRIVEN REVASCULARIZATION(17% VS 5%;P=<0.001)

16. DANAMI-3 PRIMULTI MAGNETIC RESONACE STUDY STUDIED CULPRIT VESSEL PCI VS FFR GUIDED COMPLETE REVASCULARIZATION ON INFARCT SIZE,LV FUNCTION AND REMODELLING BY CMR FFR GUIDED COMPLETE REVASCULARIZATION DID NOT AFFECT INFARCT SIZE,LV FUNCTION AND REMODELLING AS COMPARED TO CULPRIT VESSEL PCI

17. COMPARE –ACUTE TRAIL THIS STUDY ENROLLED 590 PT’S TO CULPRIT VESSEL PCI VS 295 FFR GUIDED COMPLETE REVASCULARIZATION PRIMARY END POINT WERE SIGNIFICANTLY LOWER IN FFR GUIDED COMPLETE REVASCULARIZATION [23 VS 121 HR(P<0.001)]

18. COMPLETE TRAIL -ENROLLED 4041 PT’S,140 CENTERS FROM 31 COUNTRIES 2025 PT’S -CULPRIT ONLY PCI 1353 PT’S COMPLETE REVASCULARIZATION AT INDEX HOSPITALISATION (MEDIAN 1 DAY) 663 PT’S 45 DAYS AFTER DISCHARGE (MEDIAN 23 DAYS) DURATION -3 YEARS

19. PRIMARY END POINT OF CV DEATH OR MI OCCURRED IN 7.8% IN PT’S OF COMPLETE REVASCULARIZATION VS 16.7 IN IRA PCI GROUP(P=<0.001) COMPLETE REVASCULARIZATION IS SUPERIOR TO IRA PCI IRRESPECTIVE OF TIMING OF NONCULPRIT LESION INTERVENTION

20. Major inclusion criteria Multivessel group Culprit-only group Primary endpoint PRAMI Successful treatment of the IRA and ≥ 50% stenosis in one or more coronary arteries other than the IRA Immediate multivessel PCI in non-IRAs with ≥ 50% stenosis Culprit vessel-only PCI Composite of cardiovascular death, non-fatal myocardial reinfarction or refractory angina CvLPRIT Multivessel CAD: at least 1 lesion with > 70% in one plane or > 50% in 2 planes Multivessel PCI including all non-IRAs during index admission. Single-stage complete revascularization was recommended Culprit vessel-only PCI Composite of all-cause death, reinfarction, heart failure and ischemia-driven revascularization DANAMI-3-PRIMULTI > 50% angiographic diameter stenosis in one or more non-IRA FFR-guided (≤ 0.80) multivessel PCI of all significant coronary lesions not related to the IRA 2 days after initial PCI Culprit vessel-only PCI Composite of all-cause death, reinfarction or ischemia-driven revascularization of lesions in non-IRAs COMPARE-ACUTE ≥ 50% diameter stenosis of one or more non-IRAs FFR-guided (≤ 0.80) multivessel PCI, generally during index PCI, but could be performed staged before discharge Culprit vessel-only PCI. FFR measurements of non-IRA lesions were performed but not used for decision making with respect to PCI Composite of all-cause death, reinfarction, any revascularization and cerebrovascular events COMPLETE ≥ 70% stenosis by visual estimation or 50–69% by visual estimation and accompanied FFR ≤ 0.80 Staged multivessel PCI of all suitable non-culprit lesions irrespective of symptoms or evidence of ischemia Stratified by timing of non-culprit PCI: during index hospitalization vs. after discharge but no later than 45 days after randomization Culprit vessel-only PCI, regardless of whether there was evidence of ischemia Two co-primary endpoints: (1) composite of cardiovascular death or new myocardial infarction; and (2) composite of cardiovascular death, new myocardial infarction or ischemia-driven revascularization Key features of included trials CABG  coronary artery bypass grafting,  CAD  coronary artery disease,  FFR  fractional flow reserve,  IRA  infarct-related artery,  PCI  percutaneous coronary intervention

21. Timing of Complete Revascularization with Multivessel PCI for Myocardial Infarction MULTISTARS AMI nejm.org Oct 2023

22. I mmediate versus staged complete revascularisation in patients presenting with acute coronary syndrome and multivessel coronary disease (BIOVASC ) LANCET APRIL 2023 This prospective, open-label, non-inferiority, randomised trial was done at 29 hospitals across Belgium, Italy, the Netherlands, and Spain. We included patients aged 18–85 years presenting with ST-segment elevation myocardial infarction or non-ST-segment elevation acute coronary syndrome and multivessel ( ie , two or more coronary arteries with a diameter of 2·5 mm or more and ≥70% stenosis based on visual estimation or positive coronary physiology testing) coronary artery disease with a clearly identifiable culprit lesion. A web-based randomisation module was used to randomly assign patients (1:1), with a random block size of four to eight, stratified by study centre , to undergo immediate complete revascularisation (PCI of the culprit lesion first, followed by other non-culprit lesions deemed to be clinically significant by the operator during the index procedure) or staged complete revascularisation (PCI of only the culprit lesion during the index procedure and PCI of all non-culprit lesions deemed to be clinically significant by the operator within 6 weeks after the index procedure ). The primary outcome was the composite of all-cause mortality, myocardial infarction, any unplanned ischaemia -driven revascularisation , or cerebrovascular events at 1 year after the index procedure. Secondary outcomes included all-cause mortality, myocardial infarction, and unplanned ischaemia -driven revascularisation at 1 year after the index procedure. Between June 26, 2018, and Oct 21, 2021, 764 patients (median age 65·7 years [IQR 57·2–72·9] and 598 [78·3%] males) were randomly assigned to the immediate complete revascularisation group and 761 patients (median age 65·3 years [58·6–72·9] and 589 [77·4%] males) were randomly assigned to the staged complete revascularisation group, and were included in the intention-to-treat population. In patients presenting with acute coronary syndrome and multivessel disease, immediate complete revascularisation was non-inferior to staged complete revascularisation for the primary composite outcome and was associated with a reduction in myocardial infarction and unplanned ischaemia -driven revascularisation .

23. STEMI WITH CARDIOGENIC SHOCK IT’S A SERIOUS MEDICAL CONDITION OCCURS IN 10% OF PT’S WITH ABOUT 80% OF MORTALITY. CONVENTIONAL TREATMENT IN THIS GROUP IS TO PERFORM COMPLETE REVASCULARIZATION

24. CULPRIT-SHOCK TRAIL RANDOMISED 706 PT’S TO COMPLETE VS CULPRIT ONLY REVASCULARIZATION MULTICENTRAL TRAIL PT’S ASSIGNED RANDOMLY TO EITHER CULPRIT VESSEL OR IMMEDIATE MULTIVESSEL PCI PRIMARY ENDPOINT-COMPOSITE OF DEATH OR RENAL REPLACEMENT THERAPY .

25. CULPRIT LESION MULTI VESSEL PCI AT 30 DAYS 45.9% 55.4% AT 1 YR DEATH 50% 56.9% REPEAT REVASCULARIZATION 33.2% 9.4% HF HOSPITALIZATION 5.2% 1.2% MORTALITY WAS NOT SIGNIFICANTLY DIFFERENT IN BOTH ARMS HIGHER KIDNEY INJURY WITH REPLACEMENT THERAPY OCCURRED IN MULTI VESSEL PCI

26. Early revascularization of the infarct-related artery is crucial to reduce myocardial damage and preserve myocardial function MV revascularization by PCI was a/ i a significant reduction of the combined endpoint of death and non-fatal myocardial reinfarction in STEMI patients without cardiogenic shock  INDEX MV REVASCULARIZATION IS NON-INFERIOR TO STAGED MV RE VASCULARISATION

27. PLAN FOR THE CASE P PCI +/- DES TO OM . PCI +DES TO P LAD (PT IS HEMODYNAMICALLY STABLE,SIMPLE LESION,LESS CONTRAST USED- IMMEDIATE ) RCA CTO PCI–DEPENDING ON PERSISTENT SYMPTOMS DESPITE ON OPTIMAL MEDICAL THERAPY OR ABNORMAL MYOCARDIAL PERFUSION SCAN -LATER .

28. THANK YOU