REVASCULARIZACIÓN COMPLETA vs REVASCULARIZACIÓN DEL...
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REVASCULARIZACIÓN COMPLETA vs REVASCULARIZACIÓN DEL VASO CULPABLE vs REVASCULARIZACIÓN FUNCIONAL EN PACIENTES CON INFARTO AGUDO DE MIOCARDIO José A. G. ÁLVAREZ Jefe de Hemodinamia y Cardioangiología Intervencionista Hospital Alemán - Hospital Británico Buenos Aires - Argentina [email protected]
Transcript of REVASCULARIZACIÓN COMPLETA vs REVASCULARIZACIÓN DEL...
REVASCULARIZACIÓN COMPLETA vs
REVASCULARIZACIÓN DEL VASO CULPABLE vs
REVASCULARIZACIÓN FUNCIONAL EN PACIENTES CON INFARTO AGUDO DE
MIOCARDIO
José A. G. ÁLVAREZ
Jefe de Hemodinamia y Cardioangiología Intervencionista
Hospital Alemán - Hospital Británico
Buenos Aires - Argentina
No tengo conflictos de interés en
el tema de esta exposición
Fundamentos
• Aproximadamente un 40 a 70% de los pacientes tratados con IPC en el contexto de un IAM tienen EMV
• Los pacientes con IAM + IPC + EMV tienen por lo menos el doble de mortalidad al año en comparación con los pacientes con enfermedad de un solo vaso.
Estrategias
Revascularización Completa en el momento de la Angioplastia Primaria.
Revascularización Completa en forma escalonada.
Revascularización Guiada por síntomas o pruebas funcionales.
Argumentos a favor de una Revascularización Completa • La revascularización completa ha sido asociada a una
mejor evolución alejada en enfermedad isquémica estable.
• La hipermotilidad del territorio no necrosado es importante, especialmente en pacientes con inestabilidad hemodinámica.
• Las lesiones no culpables tienen placas vulnerables que pueden transformarse en culpables.
• En el momento de la AP los pacientes están recibiendo un agresivo tratamiento antitrombótico.
• La revascularización completa disminuye la necesidad de
nuevas intervenciones.
Argumentos en contra de una Revascularización Completa
• La intervención de un vaso no culpable puede resultar en compromiso hemodinámico innecesario si existen complicaciones.
• En el STEMI hay un estado inflamatorio generalizado lo que confiere a la angioplastia mayor riesgo.
• El riesgo de que una lesión no culpable se transforme en culpable es muy bajo.
• Mayor necesidad de sustancia de contraste
2012: Guías de la Sociedad Europea de Cardiología para el manejo de pacientes con IAM con supradesnivel del segmento ST.
Primary PCI should be limited to the culprit vessel with the exception of cardiogenic shock and persistent ischaemia after PCI of the supposed culprit lesion
IIa
European Heart Journal (2012) 33, 2569–2619
2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the ACC Foundation/AHA Task Force on Practice Guidelines
CLASS III: HARM PCI should not be performed in a noninfarct artery at the time of PPCI in patients with STEMI who are hemodynamically stable . (Level of Evidence: B)
6.3 PCI of a Noninfarct Artery Before Hospital Discharge: CLASS I PCI is indicated in a noninfarct artery at a time separate from PPCI in patients who have spontaneous symptoms of myocardial ischemia. (Level of Evidence: C) CLASS IIa PCI is reasonable in a noninfarct artery at a time separate from PPCI in patients with intermediate- or high-risk findings on noninvasive testing . (Level of Evidence: B)
Bayney KR et al Am Heart J 2014;167:1-14
46.324 pts
Culprit only
38.438
Multivessel PCI
7.886
Complete vs culprit-only revascularization for patients with MVD undergoing PCI for STEMI: a systematic review and meta-analysis.
Bayney KR et al Am Heart J 2014;167:1-14
Favors MV PCI Favors Culprit Only
Complete vs culprit-only revascularization for patients with MVD undergoing PCI for STEMI: a systematic review and meta-analysis.
Index Catheterization
Staged In-hospital
Staged Elective Outpatient
Long-term mortality
Wald DS et al. N Engl J Med 2013;369:1115-1123.
Randomized Trial of Preventive Angioplasty in
Myocardial Infarction - PRAMI Trial STEMI
2428 ptes .
Revasc. Completa Inmediata
234
Revasc.Vaso Culpable
231
1922 excluidos 39 Shock Card 1122 enf de un vaso 118 con lesión de Tronco 72 con oclusión crónica 269 arteria no apropiada otros
Wald DS et al. N Engl J Med 2013;369:1115-1123.
1° end-point:
Mortalidad
IAM no fatal.
Angina Refractaria
HR 0.35 (95% CI 0.21-0.58); p<0.001
Preventive PCI
Non Preventive PCI
Pacie
nte
s s
in e
l end p
oin
t 1rio.
Randomized Trial of Preventive Angioplasty in
Myocardial Infarction - PRAMI Trial
Wald DS et al. N Engl J Med 2013;369:1115-1123.
Randomized Trial of Preventive Angioplasty in
Myocardial Infarction - PRAMI Trial
Evolución Con PCI Preventiva
(n=234)
Sin PCI Preventiva
(n=231)
HR (95%CI)
p
Mortalidad Cardíaca
4 10 0.34 (0.11-1.08)
0.07
Infarto no fatal
7 20 0.32 (0.13-0.75)
0.009
Angina Refractaria
12 30 0.35 (0.18-0.69)
0.002
Mortalidad Cardíaca más IAM no fatal
11 27 0.36 (0.18-0.73)
0.004
Wald DS et al. N Engl J Med 2013;369:1115-1123.
Randomized Trial of Preventive Angioplasty in
Myocardial Infarction - PRAMI Trial
•71% de utilización de stents
farmacoactivos.
•76% de utilización de inhibidores IIb-IIIa.
•55% a 66% de IAM Inferior.
Gershlick A et al J Am Coll Cardiol. 2015;65(10):963-972.
Complete
n=150
Culprit only
n=146
Revascularizacióh Inmediata: 59%
Revascularización escalonada: 27% (media 1.5 dias)
Solo revasc VC: 7%
Randomized Trial of Complete Versus Lesion-Only Revascularization in Patients Undergoing Primary PCI for STEMI and Multivessel Disease: The CvLPRIT Trial
MACE:
Mortalidad Global
IAM recurrente
Insuf Card
Revasc por isquemia
J Am Coll Cardiol. 2015;65(10):963-972.
Randomized Trial of Complete Versus Lesion-Only Revascularization in Patients Undergoing Primary PCI for STEMI and Multivessel Disease: The CvLPRIT Trial
HR(95%CI):0.45(0.24-0.84
P=0.009
IRA only
Complete Revascularization
J Am Coll Cardiol. 2015;65(10):963-972.
Randomized Trial of Complete Versus Lesion-Only Revascularization in Patients Undergoing Primary PCI for STEMI and Multivessel Disease: The CvLPRIT Trial
Events % IRA only (n=146)
Complete Revascularization
(n=150)
P value
MACE 21.2 10.0 .009
All-cause mortality 4.1 1.3 .14
Recurrent MI 2.7 1.3 .39
Heart faliure 6.2 2.7 .14
Repeat PCI 8.2 4.7 .2
Do We Really Know the CvLPRIT in Myocardial Infarction? Or Just Stent All Lesions?
Bhatt DL. Et al. J.Am Coll.Cardiol. 2015;65(10):973-5.
Complete Better
Mortalidad
Global
Re-infarto
Nueve revasc.
Randomise conventional PPCI, iPOST, defer stenting
627 Multivessel disease
313 IRA PCI only 314 FFR guided complete revascularisation
2239 STEMI < 12 hours
Randomise
(>50% stenosis in non IRA > 2 mm suitable for PCI)
2212 Successful infarct related artery PCI
DANAMI3-TRIAL PROGRAM
DANAMI3-PRIMULTI
Engstrom T et al Lancet. 2015 Aug 15;386(9994):665-71.
Primary endpoint DANAMI3-PRIMULTI
MACE:
Mortalidad Global
IAM
Revascularización por isquemia
Engstrom T et al Lancet. 2015 Aug 15;386(9994):665-71.
Individual components of primary endpoint DANAMI3-PRIMULTI
Composite
Non fatal MI All cause death
Revascularisation
40% of repeat revascularizations were urgent
Engstrom T et al Lancet. 2015 Aug 15;386(9994):665-71.
Multivessel coronary disease diagnosed at the time of primary PCI for
STEMI: complete revascularization versus conservative strategy. PRAGUE 13 trial
Conservative PCI
n=108 n=106
Enrolment ≥48 hours following onset of symptoms
Multivessel coronary disease diagnosed at the time of primary PCI for
STEMI: complete revascularization versus conservative strategy. PRAGUE 13 trial
Tarantini G et al J Am Coll Cardiol Intv 2016;9:1765–76
13 estudios prospectivos y 19 estudios retrospectivos. 54.148 ptes. 42.112 IRA only PCI
8.138 single procedure MV-PCI
3.898 MV-staged PCI
Survival After Varying Revascularization Strategies in Patients With STEMI and Multivessel Coronary Artery Disease A Pairwise and Network Meta-Analysis
Tarantini G et al J Am Coll Cardiol Intv 2016;9:1765–76
Long-Term Mortality
Heterogeneity p=0.06
Favors IRA-only PCI Favors Single Procedure
MV-PCI
IRA-only PCI Single proced MV PCI
Survival After Varying Revascularization Strategies in Patients With STEMI and Multivessel Coronary Artery Disease A Pairwise and Network Meta-Analysis
Tarantini G et al J Am Coll Cardiol Intv 2016;9:1765–76
Long-Term Mortality
Heterogeneity p=0.13 Favors IRA-only PCI Favors Single Procedure
MV-PCI
IRA-only PCI Single proced MV PCI
Survival After Varying Revascularization Strategies in Patients With STEMI and Multivessel Coronary Artery Disease A Pairwise and Network Meta-Analysis
Tarantini G et al J Am Coll Cardiol Intv 2016;9:1765–76
Long-Term Mortality
Heterogeneity p=0.03
Staged MV-PCI
Favors IRA-only PCI Favors Staged MV-PCI
IRA-only PCI
Survival After Varying Revascularization Strategies in Patients With STEMI and Multivessel Coronary Artery Disease A Pairwise and Network Meta-Analysis
Tarantini G et al J Am Coll Cardiol Intv 2016;9:1765–76
Long-Term Mortality
Heterogeneity p=0.27 Favors IRA-only PCI Favors Staged MV-PCI
IRA-only PCI Staged MV-PCI
Survival After Varying Revascularization Strategies in Patients With STEMI and Multivessel Coronary Artery Disease A Pairwise and Network Meta-Analysis
Tarantini G et al J Am Coll Cardiol Intv 2016;9:1765–76
Long-Term Mortality
Heterogeneity p=0.31
Favors Single Proc MV PCI Favors Staged MV-PCI
Staged MV-PCI Single proced MV PCI
Survival After Varying Revascularization Strategies in Patients With STEMI and Multivessel Coronary Artery Disease A Pairwise and Network Meta-Analysis
Tarantini G et al J Am Coll Cardiol Intv 2016;9:1765–76
Long-Term Mortality according to prevalence of 3-vessel disease
Favors staged
MV-PCI
Favors IRA-
only PCI
3-vessel disease %
MACCE: death, MI, any revasc or stroke at 12 months.
In 59% of pts. FFR of non IRA lesion (angiographic > 50% stenosis) was negative
Randomized Comparative Effectiveness Study
of Complete vs Culprit-only Revascularization
Strategies to Treat Multi-vessel Disease After Primary
Percutaneous Coronary Intervention (PCI) for ST-
segment Elevation Myocardial (STEMI) Infarction
Estimated Enrollment: 3900
Study Start Date: December 2012
Estimated Study
Completion Date:
December 2018
Estimated Primary
Completion Date:
March 2018 (Final data
collection date for
primary outcome
measure)
2013 Recommendation
2015 Focused Update Recommendation
Comment
Class III: Harm Class IIb
PCI should not be performed in a noninfarct artery at the time of primary PCI in patients with STEMI who are hemodynamically stable (11–13). (Level of Evidence: B)
PCI of a noninfarct artery may be considered in selected patients with STEMI and multivessel disease who are hemodynamically stable, either at the time of primary PCI or as a planned staged procedure (11–24). (Level of Evidence: B
Modified recommendation (changed class from “III: Harm” to “IIb” and expanded time frame in which multivessel PCI could be performed).
J Am Coll Cardiol. 2016;67(10):1235-1250
2015 ACC/AHA/SCAI Focused Update on Primary PCI for
Patients With STEMI Update
•Los estudios observacionales retrospectivos son muy
heterogéneos en selección y metodología.
•Los estudios randomizados son más homogéneos pero
tienen metodologías (y resultados) diferentes.
•La revascularización completa realizada en forma inmediata
o escalonada parece ser la mejor conducta especiamente
para los eventos extrahospitalarios.(Complete?)
•La evaluación funcional de las lesiones intermedias no
culpables puede estar condicionada por el estado
hemodinámico del paciente y la disfunción del lecho
microvascular y debe ser validada con más evidencia.
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