IAM y Enfermedad de Múltiples vasos:

Presentación del tema: "IAM y Enfermedad de Múltiples vasos:"— Transcripción de la presentación:

1 IAM y Enfermedad de Múltiples vasos:
Revascularización completa o sólo vaso culpable? Dr. Aníbal Damonte Departamento de Cardiología Intervencionista Instituto Cardiovascular de Rosario Rosario, Argentina

2 Declaro no poseer conflicto de interés en relación a esta presentación

3 Prevalencia y Pronóstico Estrategias y Recomendaciones Evidencia
Contexto del problema Prevalencia y Pronóstico Estrategias y Recomendaciones Evidencia a favor en contra Análisis de la evidencia Conclusiones

4 Contexto del problema: Prevalencia y Pronóstico
Estrategias y Recomendaciones Evidencia a favor en contra Análisis de la evidencia Conclusiones

5 Prevalencia y Pronóstico
Estudio, año N, p-PCI % MVD Mortalidad 30ds Único Vaso Mortalidad 30ds Múltiples Vasos p Moreno R, 1998 312 51% 2% 9% 0.001 Varani E, 2008 745 54% 1,3% 2,8% Stone G, 2008 3284 53,6% 1,4% 3,2% Toma M, 2010 5373 41% 3,1% 6,3% Jensen L, 2012 8822 46% 2,6% ND NA La enfermedad de multiples vasos se presenta entre el 30 y 60% de los pacientes con IAM. Esto se ha observado y se mantiene en las ultimas 3 décadas. Además se ha observado que estos pacientes con EMV tienen más del doble de mortalidad que los pacientes con lesión única en el vaso responsable del IAM. Tanto así que la EMV es considerado uno de los predictores independientes clásicos de mortalidad en el IAM, junto con la localización anterior del IAM y el KK mayor de 2 al ingreso. Moreno R. Rev Esp Cardiol 1998; 51(7): Varani E. Cathet Card Interv 2008;72: Stone G. JACC 2011; 58: Toma M. Eur Heart J 2010;31(14): Jensen L. EuroIntervention 2012;8: Predictores de mortalidad: IAM anterior, KK III-IV, EMV (OR ≥ 2)

6 Pronóstico alejado de Enf de Multiples vasos en IAM
Van der Schaaf et al:Heart 2006;92:

7 Situación del problema: Prevalencia y Pronóstico
Estrategias y Recomendaciones Evidencia a favor en contra Análisis de la evidencia Conclusiones

8 Recomendaciones: Estrategias
Pacientes con IAM-ST y enfermedad multivaso: estrategias de tratamiento PCI solo vaso culpable Revascularización Completa Tto medico optimo En un solo tiempo Evaluación funcional En dos tiempos – misma internación Cuales son las diferentes situaciones que se presentan en estos pacientes: PCI solo del vaso culpable, que luego se controlará con tratamiento óptimo o con evaluación funcional y en base a esto una posible revascularización. Revascularización completa: que puede realizarse en un tiempo, en dos tiempos en la misma internación o en otra internación. En dos tiempos – nueva internación

9 Recomendaciones: Estrategias
Pacientes con IAM-ST y enfermedad multivaso: Revascularización completa Potenciales Beneficios Potenciales Riesgos Reducción de riesgo isquémico Aumentar el tamaño del IAM Reduccion de tiempo de internación > Volumen de contraste Reduccion de costos > Riesgo de complic isquemicas < Necesidad de reintervenciones Tratar lesiones q no producen isquemia < Riesgo de ReIAM y Muerte Sobreestimar severidad de la lesión(>vasotono/vasoespasmo) < Riesgo de complic. accesos vasc 9

10 Recomendaciones: Guías Norteamericanas 2013
Recomendations Class Level Ref Primary PCI in STEMI PCI should not be performed in a noninfarct artery at the time of primary PCI in patients with STEMI who are hemodynamically stable III B Hannan. Estudio Retrospectivo, JACC 2010 Toma. Subanalisis Estudio APEX.AMI, EHJ 2010 Vlaar. Metanalisys (4 RCT-14 Retro), JACC 2011 PCI of a Noninfarct Artery Before Hospital Discharge PCI is indicated in a noninfarct artery at a time separate from primary PCI in patients who have spontaneous symptoms of myocardial ischemia I C PCI is reasonable in a noninfarct artery at a time separate from primary PCI in patients with intermediate-or high-risk findings on noninvasive testing. IIa Erne. Estudio Randomizado, SWISS II. JAMA 2007 Madsen. Randomizado, DANAMI. Circulation 1997 Las guias americanas Desaconsejan la PCI en la arteria no responsable durante la ATC primaria. Se basa en estudios no randomizados. En los pacientes con EMV, antes del alta estaria indicado PCI cuando hay sintomas espontaneos de isquemia miocardica. Consenso de experto Seria rasonable, PCI en pacientes con isquemia aun asintomaticos. Circulation 2013;127:

11 Recomendaciones: Guías Europeas 2014
Recomendations Class Level Ref Primary PCI in STEMI- Strategy. 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 B Kornowski. Subanalisis HORIZONS, JACC 2011 Hannan. Estudio Retrospectivo, JACC 2010 Toma. Subanalisis Estudio APEX.AMI, EHJ 2010 Vlaar. Metanalisys (4 RCT, 14 Retro), JACC 2011 Staged revascularization of non-culprit lesions should be considered in STEMI patients with multivessel disease in case of symptoms or ischaemia within days to weeks after primary PCI Politi. Randomizado, Heart 2010 Immediate revascularization of significant non-culprit lesions during the same procedure as primary PCI of the culprit vessel may be considered in selected patients IIb Wald. Randomizado. Estudio PRAMI, NEJM 2013 Las guias Europeas 2014, de forma similar aunque un poco más actualizadas, aconsejan solo la PCI del vaso culpable a menos que exista compromiso hemodinámico severo. La PCI en dos tiempos se aconseja en los pacientes con sintomas o isquemia, a realizarse entre dias a semanas. La PCI del vaso no culpable en el mismo tiempo que la pPCI, solo en pacientes selectos. EuroIntervention 2015;10:

12 Situación del problema: Prevalencia y Pronóstico Recomendaciones
Evidencia a favor en contra Análisis de la evidencia Conclusiones De acuerdo a lo que observamos en las Referencias de las guias, 4 RCT (1997, 2007, 2010 y 2013) 1 ENR 2 Subanalisis y 1 Meta, uno podria pensar que existe poca evidencia actual, sin embargo en los ultimos 5 años son muchos los estudios retrospectivos, randomizados y metanalisis.

13 Evidencia FAVOR PCI-MV NO DIFERENCIA FAVOR VASO CULPABLE
Briasoulis A, RCT, IJC 2015 Sethi A, Mixto, CCI 2011 Zhang D, Pareado, Mixto, PlOne 2014 El-Hayec G, RCT, AJC 2015 Lu D, Pareado, Mixto, KJMS 2013 Elgendy I, NRCT, IJC 2015 Vlaar P, Pareado, Mixto, JACC 2011 Bangalore S, TSA, RCT, Circul C Int 2015 Jensen L, Retrospectivo, Eurointerv 2012 Qarawani D, Retrospectivo, IJC 2008 Hannan E, Retrospectivo, JACC Int 2010 Varani E, Retrospectivo, CCI 2008 Gran controversia con los resultados de los estudios publicados, algunos a favor de PCI-MVD, otros a favor de solo vaso culpable, y otros sin diferencia. Igbal M, Retrospectivo, CircCQO 2014 Politi L, Randomizado, Heart 2010 Di Mario C, Randomizado, IJCI 2004 PRAMI Trial, Randomizado, NEJM 2013 CVLPRIT Trial, Randomizado, JACC 2015 DANAMI 3 Trial, Randomizado, AHJ 2015 PRAGUE 13 Trial, Randomizado, PCR 2015

14 Situación del problema: Prevalencia y Pronóstico Recomendaciones
Evidencia a favor en contra Análisis de la evidencia Conclusiones

15 Análisis de la evidencia
Estudios Randomizados

16 A randomised trial of target-vessel versus multi-vessel PCI in ST-AMI: major adverse cardiac events during long-term follow-up. 2010 779 Pts. IAM-ST ( ) 263 (33.7%) MVD 49 Pts excluidos: Shock, LM, CABG, Valvul 214 Pts. IAM-ST y MVD. PCI-VC (84 Pts: COR) PCI-MV un tiempo (65 Pts: durante p-PCI: CR) PCI-MV dos tiempos (65 Ptes: 58±12 dias: SR) 1. Culprit-only revascularisation (COR): the IRA only was dilated and the other arteries were left untreated. 2. Staged revascularisation (SR): the IRA only was treated during the primary intervention while the complete revascularisation was planned in a second procedure. 3. Complete revascularisation (CR): the IRA was opened followed by dilatation of other significantly narrowed arteries during the same procedure. MACE: Muerte - Muerte cardíaca - Re-IAM - Hospitalización por SCA - Nueva PCI Politi L. Heart 2010;96:

17 Politi et al. Randomized PCI-VC vs PCI-MV in STEMI
A diferencia de los anteriores, en este Estudio randomizado la estrategia de PCI vaso culpable fue peor que las demas incluyendo MVPCI en el mismo acto. . The primary endpoint of the study was the incidence of major adverse cardiac events (MACE) defined as cardiac or non-cardiac death, inhospital death, re-infarction, re-hospitalisation for acute coronary syndrome and repeat coronary revascularisation. For repeat revascularisation we included all PCI or CABG occurring after the baseline procedure and justified by recurrent symptoms, re-infarction or objective evidence of significant ischaemia on provocative testing Multivariable predictors of MACE The reduced risk of MACE in the SR and CR groups was maintained even after multivariable adjustment for age, gender, diabetes mellitus, LVEF before PCI, Killip class, chronic renal failure and CIN. At multivariable analysis, independent predictors of MACE were COR, chronic renal failure and Killip class. Survival free of MACE was worse in the COR group compared with both the CR group (p¼0.002) and the SR group (p¼0.001), whereas it was similar between the CR and SR groups (p0.815). CONCLUSIONS. In a contemporary homogeneous cohort of patients with STEMI and multivessel CAD treated with primary PCI, COR angioplasty was associated with the highest rate of MACE compared with multivessel treatment. Patients scheduled for staged revascularisation experienced a similar rate of MACE to patients undergoing complete simultaneous treatment of non-IRA. This novel finding of our study should promote further research in order to provide strong enough evidence that may eventually update the current recommendations for patients with multivessel CAD and STEMI. Politi L. Heart 2010;96:

18 Politi et al. Randomized PCI-VC vs PCI-MV in STEMI
Sobrevida libre de MACE PCV-MV (2) PCV-MV (1) PCV-VC Survival free of MACE was worse in the COR group compared with both the CR group (p¼0.002) and the SR group (p¼0.001), whereas it was similar between the CR and SR groups (p0.815). CONCLUSIONS. In a contemporary homogeneous cohort of patients with STEMI and multivessel CAD treated with primary PCI, COR angioplasty was associated with the highest rate of MACE compared with multivessel treatment. Patients scheduled for staged revascularisation experienced a similar rate of MACE to patients undergoing complete simultaneous treatment of non-IRA. This novel finding of our study should promote further research in order to provide strong enough evidence that may eventually update the current recommendations for patients with multivessel CAD and STEMI. Politi L. Heart 2010;96:

19 Randomized Trial of Preventive Angioplasty in Myocardial Infarction: PRAMI Trial 2013
PCI-MV (un tiempo) PCI-VC Este estudio comparó la estrategia de PCI en MVD con más del 50% lesion en vaso no culpable (angioplastia preventiva en el mismo acto) vs tratamiento solo del vaso culpable. The primary outcome was a composite of death from cardiac causes, nonfatal myocardial infarction, or refractory angina, and each of the components was also assessed individually. Secondary outcomes were death from noncardiac causes and repeat revascularization procedures (PCI or CABG). In this trial, all decisions regarding the treatment of patients, other than the random assignments to the two study groups, were left to the discretion of the clinicians involved. . Wald D. N Engl J Med 2013;369:

20 Detención precoz del estudio por el comité de seguridad.
Wald D et al. PRAMI Trial Detención precoz del estudio por el comité de seguridad. PCI-MV PCI-VC El estudio se detuvo precozmente por el comité de seguridad, con 465 pacientes (se iban a enrolar 600), debido a la marcada mejoria del tratamiento MVDPCI. The combined rate of cardiac death, nonfatal myocardial infarction, or refractory angina was reduced by 65%, an absolute risk reduction of 14 percentage points over 23 months. The effect was similar in magnitude and remained highly significant when the analysis was limited to cardiac death and nonfatal myocardial infarction. . In the group receiving no preventive PCI, ischemia testing was performed in about one third of patients: 44 tests in asymptomatic patients (usually ≤6 weeks after the myocardial infarction) and 37 tests in patients with chest pain. In the preventive-PCI group, ischemia testing was performed in about one sixth of patients: 8 tests in asymptomatic patients and 31 tests in patients with chest pain. Although such testing was not a prespecified trial outcome, these findings suggest that preventive PCI may lead to less ischemia testing and that when such testing is performed, it tends to be in patients with symptoms.. The results of this trial show that in patients with acute STEMI, the use of preventive PCI to treat noninfarct coronary-artery stenoses immediately after PCI in the infarct artery conferred a substantial advantage over not performing this additional procedure. The combined rate of cardiac death, nonfatal myocardial infarction, or refractory angina was reduced by 65%, an absolute risk reduction of 14 percentage points over 23 months. The effect was similar in magnitude and remained highly significant when the analysis was limited to cardiac death and nonfatal myocardial infarction. Wald D. N Engl J Med 2013;369:

21 Wald D et al. PRAMI Trial www.icronline.com
Conclusions. In patients with STEMI and multivessel coronary artery disease undergoing infarctartery PCI, preventive PCI in noninfarct coronary arteries with major stenoses significantly reduced the risk of adverse cardiovascular events, as compared with PCI limited to the infarct artery Wald D. N Engl J Med 2013;369:

22 Randomized Trial of Complete Versus Lesion-Only Revascularization in Patients Undergoing Primary PCI for STEMI and Multivessel Disease. CvLPRIT Trial 64% en el mismo procedimiento MACE: D, MI, HF, IDR If randomized to complete revascularization, it was mandated that the IRA be treated first. If there were no clinical contraindications, complete revascularization was recommended at the same sitting to reduce multiple vascular punctures, avoid prolonged hospitalization, and attenuate potential patient dropout. If the operator decided for clinical reasons that the procedure be staged, it was mandated that the N-IRA be treated during the index admission. For safety reasons, all patients were scheduled for myocardial perfusion scintigraphy (MPS) at 6 2 weeks after discharge to assess residual ischemia. Scans were “nested” (used for study purposes only) but, for safety reasons, made available to physicians if the ischemic burden was >20%. . On the basis of the operator’s clinically driven decision, 64% of the complete revascularization group received N-IRA revascularization at the same procedural session as IRA P-PCI. Gershlick A. JACC 2015;65:963–72

23 Gershlick A. CvLPRIT Trial
PCI-MV PCI-VC Hubo diferencia en los MACE, pero no en los puntos por separado Gershlick A. JACC 2015;65:963–72

24 Impacto en la práctica diaria

25 Impacto en la práctica diaria

26 Pero. todas esas lesiones necesitan realmente tratamiento
Pero.... todas esas lesiones necesitan realmente tratamiento?...Todas generan isquemia?

27 Non-culprit lesions detected during primary PCI: treat invasively or follow the guidelines? A randomized study Tratamiento Conservador vs Invasivo (guiado por FFR) de la lesión no culpable 121 pts IAM-MVD Random 2:1 Conservador 41 pts. Invasivo 80 pts. Endpoint: FEY 6meses MACE: Muerte, reIAM, rePCI FFR FFR<0.75 In this randomised trial, we hypothesised that early ischaemia guided revascularisation after primary PCI would result in an improvement of global left ventricular function and less cardiac events during follow-up when compared to a more conservative treatment strategy. The aim was to include a total of 300 patients in the study. FFR>0.75 PCI CABG Conservador Dambrink JH. EuroIntervention 2010;5:

28 Dambrink et al. CVR vs MVPCI, FFR
121 pts IAM-MVD Random 2:1 Conservador 41 pts. Invasivo 80 pts. 15 pts no realizado FFR 65 pts (91 les) FFR<0.75: 42 pts (50 les, 55%) Si bien este estudio no tiene poder estadístico para los puntos duros, hubo un hecho importante que fue que en el 45% de las lesiones randomizadas a tratamiento invasivo el FFR fue negativo, por lo que no fueron realizadas. FFR>0.75: 23 pts (41 les, 45%) PCI 41 pts CABG 1 pt Conservador 23 pts Dambrink JH. EuroIntervention 2010;5:

29 The Third DANish Study of Optimal Acute Treatment of Patients with STEMI: DANAMI 3 trial.
Se comparó un grupo de PCI-VC vs PCI-MV en dos tiempos intrahospitalario (2-4 dias) guiado por FFR MACE All-cause mortality Nonfatal myocardial infarction Ischemia driven revascularisation of non IRA lesions ACC 2015 EuoPCR 2015

30 DANAMI 3 trial. www.icronline.com ACC 2015 EuoPCR 2015
Conclusion. Complete FFR guided revascularisation of multivessel disease in STEMI patients, staged within the index admission, reduced the primary endpoint of all cause death, reinfarction and repeat revascularisation 40% of repeat revascularisations were urgent. However, the reduction in the primary endpoint was driven by repeat revascularisations and not by hard endpoints Therefore, although complete revascularisation should be recommended, any condition that makes complex PCI unattractive may support a more conservative strategi of IRA PCI only ACC 2015 EuoPCR 2015

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33 Treatment of STEMI with Multi-vessel CAD
No shock shock Simple CAD Complex CAD + LAD LV circulatory support - ECMO - Impella - IABP 2VD Same procedure Pre-discharge Complete Revascularization 3VD Staged procedure FFR-guided Tx CABG Complete revascularization Intermediate CAD complexity 2VD LAD Pre-discharge FFR-guided (Functional Syntax) Complete Revascularization Same procedure 3VD LAD CTO or failure FFR- FFR assessment Or non invasive OMT No LAD Staged procedure FFR+ PCI

34 Conclusiones La enfermedad de múltiples vasos en el IAM es una condición frecuente y de mal pronóstico. La evidencia actual no permite establecer qué tipo de estrategia de revascularización es la más adecuada para los pacientes estables. Si se optara por revascularización completa, la estrategia en dos tiempos, intra o extra hospitalaria parece ser la mejor opción. La utilización de FFR en la lesión no culpable puede colaborar en discriminar las lesiones a revascularizar. La revascularización de la lesión no culpable debería se individualizada.

35 Conclusiones Varios estudios randomizados que se encuentran en la fase de reclutamiento podrían aclarar nuestras enormes dudas: COMPLETE Trial CROSS-AMI PRIME-TIME COMPARE-ACUTE

36 Muchas gracias

37

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39 Metanalisis. Bangalore et al
PCI-VC vs PCI-MV en un/dos tiempos MACE (muerte, IAM, revascularización) Efficacy and safety outcomes were evaluated. Efficacy outcomes were long-term major adverse cardiovascular events (MACE), as well as death, cardiovascular death, nonfatal MI, and revascularization. Safety outcomes were contrast-induced nephropathy, volume of contrast administered, and procedure time. . With 5 trials and 233 events, complete revascularization was associated with significant reduction in MACE (14.2% versus 27.2%; incident rate ratio [RR] 0.48; 95% confidence interval [CI] 0.37–0.61) when compared with culprit-only revascularization MACE: muerte, IAM y Revasc PCI-MV PCI-VC Bangalore S. Circ Cardiovasc Interv. 2015;8:e002142

40 Metanalisis Bangalore et al.
Analisis Secuencial: MACE Trial sequential analysis (TSA) for the outcome of MACE. The required information size is based on an anticipated intervention effect of 25% relative risk reduction, a control event proportion estimated from the cumulated culprit-only revascularization event proportion, and a diversity =25%, α=0.05, and β=0.20. . In the TSA, the cumulative z-curve crossed both the traditional boundary (P=0.05) and the trial sequential monitoring boundary, indicating that there is firm evidence for a 25% reduction in MACE with complete revascularization when compared with culprit-only revascularization. Trial Sequential Analysis Cumulative meta-analyses and repetitive testing of accumulating data run the risks of producing type I and type II errors. TSA is similar to interim analyses in a single trial, where monitoring boundaries are used to decide whether a trial could be terminated early when a P value is sufficiently small to show the anticipated effect or for futility. TSA was performed using standard software (TSA ver 0.9 Beta)16 anticipating a 25% relative risk reduction for efficacy outcome, α=5% and 1−β=80% and estimating the required diversity adjusted information size. The methodology has been described previously.17,18 The 25% relative reduction was chosen because this is the nominal effect size seen in cardiovascular trials that is both clinically meaningful and realistic. For TSA, trial sequential monitoring boundaries are drawn for each outcome, similar to interim analysis of randomized trials and provides information as to whether to continue evaluating for evidence (eg, continue the COMPLETE trial) when the boundary is not crossed or whether sufficient evidence is reached for anticipated effect or for futility when the boundary is crossed. The interpretation is similar to that of DeMets stopping boundaries for clinical trials. Firme evidencia para una reducción del 25% en MACE con la PCI-MV Bangalore S. Circ Cardiovasc Interv. 2015;8:e002142

41 Metanalisis Bangalore et al.
Muerte CV RR: 0.38 ( ) IAM RR: 0.64 ( ) With 5 trials and 68 deaths, complete revascularization was associated with significant reduction in death (4.5% versus 7.5%; RR=0.60; 95% CI 0.38–0.97) when compared with culprit-only revascularization. However, in the TSA, the cumulative z-curve crossed the traditional boundary (P=0.05) but not the trial sequential monitoring boundary, indicating lack of a firm evidence for a 25% reduction in death with complete revascularization when compared with culprit-only revascularisation. Results were largely similar for cardiovascular death with significant reduction in cardiovascular death with complete versus culprit-only revascularization (2.3% versus 5.6%; RR=0.38, 95% CI 0.20–0.73), but the TSA indicating lack of firm evidence for a 25% reduction with the accumulated information size. With 5 trials and 59 events, there was numerically lower MI with complete revascularization when compared with culprit-only revascularization, but this was not statistically significant (4.2% versus 6.2%; RR=0.64; 95% CI 0.37–1.08) (Figure 4A). There was moderate heterogeneity in the analysis (I2=41%), which was explained by the Dambrink et al trial. Exclusion of this trial showed that complete revascularization was associated with a 59% reduction in MI when compared with culprit-only revascularization (RR=0.41; 95% CI 0.23–0.76). There was no heterogeneity in this analysis. In the TSA, the cumulative z-curve failed to cross both the traditional boundary (P=0.05) and the trial sequential monitoring boundary, indicating lack of firm evidence for a 25% reduction in MI with complete revascularization compared with culprit-only revascularization (Figure 4B). In the sensitivity analysis excluding the trial by Dambrink et al, the cumulative z-curve crossed the traditional boundary (P=0.05) but not the trial sequential monitoring boundary, indicating lack of firm evidence for a 25% reduction in MI with complete versus culprit-only revascularization. Revasc RR: 0.42 ( ) Bangalore S. Circ Cardiovasc Interv. 2015;8:e002142

42 Dambrink et al. CVR vs MVPCI, FFR
Endpoint: FEY 6meses Figure 2. Left ventricular ejection fraction assessed by radionuclide ventriculography in both treatment groups at baseline and after six months (primary endpoint) is depicted. The primary endpoint was available in 90/121 (74%) of the patients. There was no significant difference between the two treatment groups Figure 3. Major cardiac adverse events up to six months of follow-up in both treatment groups (intention-to-treat analysis) are shown. Most events were more frequent in invasively treated patients, except repeat PCI procedures. The difference in the combination of death and myocardial infarction was statistically significant. Figure 4. Major cardiac adverse events up to six months of follow-up is depicted in a subgroup of patients that actually was treated according to their randomisation assignment (per protocol analysis in 105 patients). In this analysis, the difference in death and myocardial infarction (Figure 3) was no longer significant. There was a strong trend towards more PCI procedures in the conservative group in this subset. Non-culprit PCI’s were significantly more frequent in the conservative group (22 vs. 6 %, p = 0.017). Conclusions. In selected patients with relatively preserved left ventricular function, it is unlikely that an invasive strategy towards non-culprit lesions detected during primary angioplasty further improves ejection fraction. The haemodynamic significance of these nonculprit lesions is frequently overestimated (40%). Compared to a conservative strategy, an early ischaemia-guided invasive strategy prevents later PCI procedures but does not result in a reduction of total major adverse cardiac events at six months. These findings support a conservative strategy as currently advocated by the guidelines in these patients. Dambrink JH. EuroIntervention 2010;5:

43 DANAMI 3 trial. ACC 2015 EuoPCR 2015

44 PCI vaso culpable vs PCI-MV dos tiempos (entre 3-40 dias)
Multivessel coronary disease diagnosed at the time of primary PCI for STEMI: complete revascularization versus conservative strategy. PRAGUE 13 trial PCI vaso culpable vs PCI-MV dos tiempos (entre 3-40 dias) 214 pts IAM-MVD ( ) PCI-VC 108 pts. PCI-MV 106 pts. MACE: Muerte, IAM, Stroke FUP: 36 meses Hlinomaz O. EuroPCR 2015

45 Hlinomaz et al. PRAGUE 13 trial
Hlinomaz O. EuroPCR 2015

46 Hlinomaz et al. PRAGUE 13 trial
Hlinomaz O. EuroPCR 2015

47 Practica diaria: Publicaciones
Estudio HORIZONS-AMI: 18% de los pacientes sometidos a PCI de múltiples vasos, pero solo 1.5% estaba en shock cardiogénico Estudio APEX-AMI: 9.9% sometido a PCI múltiples vasos y solo el 1% estaba en clase Killip IV Registro del Estado de New York: 12.5% sometido PCI múltiples vasos y solo 4.4% tenia compromiso hemodinámico. Entonces, las guias solo recominendan la PCI del vaso culpable a menos que exista compromiso hemodinámico, pero en la practica diaria publicada en los registros no sucede esto, sino que parece haber una selección de pacientes, más allá aquellos con compromiso hemodinámico.