Immediate Multivessel PCI after delayed presentation in acute myocardial infarction

Hanumanthu, Jagan

Background
Patients in acute coronary syndrome often present with multivessel coronary artery disease. Current guidelines recommend complete revascularization in selected patients with STEMI and multivessel disease, either at index primary percutaneous coronary intervention (PCI) or as a staged procedure (IIb recommendation). We wanted to assess the efficacy and harm of immediate complete revascularization at index PCI in patients with delayed presentation of acute coronary syndrome.

Methods
We performed a retrospective review of patients who presented to a tertiary care hospital in Goa, India 6 hours after chest pain onset and underwent multivessel (including non culprit vessels) PCI from 2016-2018. Primary outcome was a composite of death and renal dysfunction requiring renal replacement therapy at 30 days. Descriptive statistics was used to analyze the data.

Results
Among the 90 patients that underwent multivessel PCI, 76 (84%) were immediate and 14 (16%) were staged procedures. Median age was 61 years (IQR 53-69), 77 (86%) males, 56 (62%) diabetic and 59 (66%) hypertensive patients, 9 (10%) of whom underwent thrombolysis prior to admission. 77 (86%) had STEMI and others were NSTE-ACS. Renal dysfunction on admission was 7(8%) and 75 (83%) were in pulmonary edema, 73 (81%) of whom required noninvasive and invasive ventilatory support. 66(76%) patients were in cardiogenic shock needing catecholamine support. Triple vessel disease was noted in 31 (34%) patients. Culprit vessel was RCA in 34(38%), LAD in 42(47%), LCX in 11(12%), Left main in 2(2%) and Ramus in 1 patient. Balloon pump support was utilized in 2(2%) patients. Median contrast use was higher in staged procedures 335 ml(IQR: 310-380ml) vs 200 ml(IQR: 180-220ml) in immediate procedures (p<0.001). Other baseline characteristics were similar. Primary outcome occurred as 3 (3%) deaths since 7(8%) patients developed acute kidney injury but did not require dialysis. There was no difference between these outcomes in immediate or staged procedures (Chi2 0.45 and 0.24 respectively)

Conclusions:
Immediate complete revascularization at index PCI is feasible and safe in ACS patients with delayed presentation including those with cardiogenic shock.