Revascularization of myocardial infarction without ST segment elevation in multivessel coronary artery disease

   Many patients with non-ST elevation myocardial infarction have multivessel coronary artery disease, which complicates the course of the disease and is associated with fatal outcomes. Most patients with non-ST elevation myocardial infarction undergo coronary angiography and revascularization during initial hospitalization. However, the decision to perform total or incomplete revascularization and whether to perform total revascularization on admission or at the stage of its implementation is complex and must be adapted to the age, general condition of the patient and comorbidities. Since
the majority of patients with non-STelevation myocardial infarction have multivessel disease, treatment and timing are critical components to ensure favorable outcomes. Early revascularization is associated with improved long-term patient outcomes, but the optimal approach to revascularization in patients with non-ST elevation myocardial infarction with multivessel disease remains poorly understood. However, in this patient population, a multidisciplinary cardiac approach is recommended to determine revascularization options. Published data suggest that evaluation of the risk-benefit associated with future invasive procedures should be based on an analysis of the patient's general condition and cardiovascular risk factors, the ability to identify the culprit artery, the technical feasibility of performing multivessel revascularization, and the location, degree of stenosis, and severity of lesions.Whether multivessel percutaneous coronary intervention or coronary artery bypass grafting provides better outcomes in patients with non-ST elevation myocardial infarction remains largely debatable. In this connection, it is relevant to conduct prospective studies to study the optimal revascularization strategies.

1. Case BC, Weintraub WS. Non–ST‐Segment–Elevation Myocardial Infarction: When Is Rapid Revascularization Critical? Journal of the American Heart Association. 2021;10(19):e023645. doi: 10.1161/JAHA.121.023645

2. Ryabov V.V., Gombozhapova A.E., Demyanov S.V. Profile of a patient with non-ST segment elevation myocardial infarction in actual clinical practice. Russian Journal of Cardiology. 2021;26(2):4071. (In Russ.). doi: 10.15829/1560-4071-2021-4071

3. Neverova Yu.N., Tarasov R.S., Nagirnyak O.A. Main predictors of in-hospital adverse outcomes in non-ST elevation acute coronary syndrome patients with multivessel disease. Cardiovascular Therapy and Prevention. 2018;17(4):19-25. (In Russ.). doi: 10.15829/1728-8800-2018-4-19-25

4. Bajraktari G, Henein MY. Treatment strategies of NSTEMI-ACS with multivessel disease. IntCardiovasc F J, 2016;6:3-5. doi: 10.17987/icfj.v6i0.211

5. Sanchis-Gomar F, Perez-Quilis C, Leischik R, Lucia A. Epidemiology of coronary heart disease and acute coronary syndrome. Ann Transl Med. 2016;4(13):256. doi: 10.21037/atm.2016.06.33

6. Nadlacki B, Horton D, Hossain S, Hariharaputhiran S, Ngo L, Ali A. et al. Long term survival after acute myocardial infarction in Australia and New Zealand, 2009-2015: a population cohort study. Med J Aust. 2021;214(11):519-525. doi: 10.5694/mja2.51085

7. Jobs A, Mehta SR, Montalescot G, Vicaut E, Van't Hof AWJ, Badings EA. et al. Optimal timing of an invasive strategy in patients with non‐ST‐elevation acute coronary syndrome: a meta‐analysis of randomised trials. Lancet. 2017;390:737–746. doi: 10.1016/S0140-6736(17)31490-3

8. Tarasov R.S., Neverova Yu.N., Ganyukov V.I., Ivanov S.V., Nagirnyak O.A., Barbarash O.L. et al. The results of myocardial revascularization in non-ST-elevation acute coronary syndrome patients and multivessel disease. Cardiovascular Therapy and Prevention. 2017;16(2):52-58. (In Russ.). doi: 10.15829/1728-8800-2017-2-52-58

9. Roffi M, Patrono C, Collet JP, Mueller Ch, Valgimigli M, Andreotti F. et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J.2016;37:267-315. doi: 10.1093/eurheartj/ehv320

10. Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL. et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021;42(14):1289-1367. doi: 10.1093/eurheartj/ehaa575

11. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U. et al. 2018 ESC/EACTS guidelines on myocardial revascularization. Eur Heart J.2019;40:87-165. doi: 10.4244/EIJY19M01_01

12. Kofoed KF, Kelbæk H, Hansen PR, Torp‐Pedersen C, Høfsten D, Kløvgaard L. et al. Early versus standard care invasive examination and treatment of patients with non‐ST‐segment elevation acute coronary syndrome. Circulation. 2018;138:2741–2750. doi: 10.1161/CIRCULATIONAHA.118.037152

13. Mehta SR, Granger CB, Boden WE, Steg PG, Bassand J‐P, Faxon DP, et al. Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med.2009;360:2165–2175. doi: 10.1056/NEJMoa0807986

14. Arora S, Matsushita K, Qamar A, Stacey RB, Caughey MC. Early versus late percutaneous revascularization in patients hospitalized with non ST‐segment elevation myocardial infarction: the Atherosclerosis Risk in Communities Surveillance Study. Catheter Cardiovasc Interv.2018; 91:253–259. doi: 10.1002/ccd.27156

15. Thiele H, Rach J, Klein N, Pfeiffer D, Hartmann A, Hambrecht R. et al.Optimal timing of invasive angiography in stable non‐ST‐elevation myocardial infarction: the Leipzig Immediate versus early and late PercutaneouS coronary Intervention triAl in NSTEMI (LIPSIA‐NSTEMI Trial). Eur Heart J.2012;33:2035–2043. doi: 10.1093/eurheartj/ehr418

16. Montalescot G, Cayla G, Collet J‐P, Elhadad S, Beygui F, Le Breton H, et al. Immediate vs delayed intervention for acute coronary syndromes: a randomized clinical trial. JAMA. 2009; 302:947–954. doi: 10.1001/jama.2009.1267

17. Neumann FJ, Kastrati A, Pogatsa‐Murray G, Mehilli J, Bollwein H, Bestehorn HP, et al. Evaluation of prolonged antithrombotic pretreatment ("cooling‐off" strategy) before intervention in patients with unstable coronary syndromes: a randomized controlled trial. JAMA. 2003; 290:1593–1599. doi: 10.1001/jama.290.12.1593

18. van 't Hof AW, de Vries ST, Dambrink JH, Miedema K, Suryapranata H, Hoorntje JC, et al. A comparison of two invasive strategies in patients with non‐ST elevation acute coronary syndromes: results of the Early or Late Intervention in unStable Angina (ELISA) pilot study. 2b/3a upstream therapy and acute coronary syndromes. Eur Heart J.2003;24:1401–1405. doi: 10.1016/s0195-668x(03)00259-8

19. Fagel ND, Leuven SGJ, Kikkert WJ, de Leau MM, van Heerebeek L, Riezebos RK. The Effect of the Timing of Invasive Management on Cardiac Function in Patients with NSTE-ACS, Insights from the OPTIMA-2 Randomized Controlled Trial. Journal of Clinical Medicine. 2021; 10(16):3636. doi: 10.3390/jcm10163636

20. Chang M, Lee CW, Ahn JM, Cavalcante R, Sotomi Y, Onuma Y, et al. Comparison of Outcome of Coronary Artery Bypass Grafting Versus Drug-Eluting Stent Implantation for Non-ST-Elevation Acute Coronary Syndrome. Am J Cardiol. 2017;120(3):380-386. doi: 10.1016/j.amjcard.2017.04.038

21. Hamaya R, Chang YT, Chewcharat A, Chiu N, Yonetsu T, KakutaT. et al.Comparison of invasive treatment strategies in patients with non–ST elevation acute coronary syndrome : A systematic review and meta-analysis. JTCVS Open.2021;8:323-335. doi: 10.1016/j.xjon.2021.08.028

22. Ram E, Sternik L, Klempfner R, Iakobishvili Z, Peled Y, Shlomo N. et al. Outcomes of different revascularization strategies among patients presenting with acute coronary syndromes without ST elevation. J Thorac Cardiovasc Surg.2020;160:926-935.e6. doi: 10.1016/j.jtcvs.2019.08.130

23. Buszman PE, Buszman PP, Bochenek A, Gierlotka M, Gąsior M, Milewski K, et al. Comparison of stenting and surgical revascularization strategy in non-ST elevation acute coronary syndromes and complex coronary artery disease (from the Milestone Registry). Am J Cardiol. 2014;114(7):979-87. doi: 10.1016/j.amjcard.2014.07.008

24. Li T, Jia S, Liu Y, Yao Y, Song Y, Tang X, et al. Long-Term Outcomes of Single-Vessel Percutaneous Coronary Intervention on Culprit Vessel vs. Multivessel Percutaneous Coronary Intervention in Non-ST-Segment Elevation Acute Coronary Syndrome Patients WithMultivessel Coronary Artery Disease. Circ J. 2021;85(2):185-193. doi: 10.1253/circj.CJ-20-0369

25. Case BC, Yerasi C, Wang Y, Forrestal BJ, Hahm J, Dolman S, et al. Admissions rate and timing of revascularization in the United States in patients with non‐ST‐elevation myocardial infarction. Am J Cardiol.2020;134:24–31. doi: 10.1016/j.amjcard.2020.08.010

26. Correia C, Galvao Braga C, Martins J, Arantes C, Abreu G, Quina C. et al. Multivessel vs. culprit-only revascularization in patients with non-ST-elevation acute coronary syndromes and multivessel coronary disease. Rev Port. Cardiologia. 2018;37(2):143–154. doi: 10.1016/j.repce.2017.05.011

27. Jang JS, Jin HY, Seo JS, Yang T-H, Kim D-K, Kim D-S, et al. Meta-analysis of multivessel versus culprit-only percutaneous coronary intervention in patients with non-ST-segment elevation acute coronary syndrome and multivessel coronary disease. Am J Cardiol, 2015;115:1027-1032. doi: 10.1016/j.amjcard.2015.01.530

28. Mariani J, Macchia A, De Abreu M, Gonzalez Villa Monte G, Tajer C. Multivessel versus Single Vessel Angioplasty in Non-ST Elevation Acute Coronary Syndromes : A Systematic Review and Metaanalysis. PLoS ONE, 2016;11(2): e0148756. doi: 10.1371/journal.pone.0148756

29. Salem M, Farag S, Atia AI, Seleem M, Mansour H. Multivessel stenting versus culprit-only stenting in multivessel coronary artery disease patients presented with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). J Cardiol Current Res, 2015;3(6): 00122. doi: 10.15406/jccr.2015.03.00122

30. Huckaby LV, Sultan I, Mulukutla S, Kliner D, Gleason TG, Wang Y, et al. Revascularization following non-ST elevation myocardial infarction in multivessel coronary disease. J Card Surg. 2020;35(6):1195-1201. doi: 10.1111/jocs.14539

31. Mulukutla SR, Gleason TG, Sharbaugh M, Sultan I, Marroquin OC, Thoma F, et al. Coronary Bypass Versus Percutaneous Revascularization in Multivessel Coronary Artery Disease. Ann Thorac Surg. 2019;108(2):474-480. doi: 10.1016/j.athoracsur.2019.02.064

32. Morawska I, Niemiec R, Stec M, Wrona K, Bańka P, Swinarew A, et al. Total Occlusion of the Infarct-Related Artery in Non-ST-Elevation Myocardial Infarction (NSTEMI)-How Can We Identify These Patients? Medicina (Kaunas). 2021;57(11):1196. doi: 10.3390/medicina57111196

33. Sipahi I, Akay MH, Dagdelen S, Blitz A, Alhan C. Coronary artery bypass grafting vs percutaneous coronary intervention and long-term mortality and morbidity in multivessel disease: meta-analysis of randomized clinical trials of the arterial grafting and stenting era. JAMA InternMed. 2014;174(2):223-30. doi: 10.1001/jamainternmed.2013.12844

34. Kim MC, Hyun Ju Yong, AhnYoungkeun, Bae SungA, Hyun Dae Young, Cho Kyung Hoon et al. Optimal Revascularization Strategy in Non–ST‐Segment–Elevation Myocardial Infarction WithMultivessel Coronary Artery Disease: Culprit‐Only Versus One‐Stage Versus Multistage Revascularization. Journal of the American Heart Association. 2020;9:e016575. doi: 10.1161/JAHA.120.016575

35. Alıcı G, Quisi A, Genc O, Harbalıoğlu H, Allahverdiyev S, Yıldırım A, et al. Mortality Outcomes of Single-staged versus Multi-staged Complete Coronary Revascularization in Multivessel Non-ST Elevation Myocardial Infarction Patients.Duzce Medical Journal, 2021;23(2):129-136. doi: 10.18678/dtfd.868952

36. Rathod KS, Koganti S, Jain AK, Astroulakis Z, Lim P, Rakhit R, et al. Complete Versus Culprit-Only Lesion Intervention in Patients With Acute Coronary Syndromes. J Am CollCardiol. 2018;72(17):1989-1999. doi: 10.1016/j.jacc.2018.07.089

37. Zaman MO, Mojadidi MK, Elgendy IY. Revascularization strategies for patients with myocardial infarction and multi-vessel disease: A critical appraisal of the current evidence. J GeriatrCardiol. 2019;16(9):717-723. doi: 10.11909/j.issn.1671-5411.2019.09.001