Читать книгу Practical Cardiovascular Medicine - Elias B. Hanna - Страница 113

Approximately 50–60% of patients presenting with STEMI have multivessel CAD, and up to 40% have multiple complex plaques.^45,61,68

The traditional teaching had been to only treat the culprit artery in hemodynamically stable patients, and to concomitantly treat culprit and non-culprit arteries in cardiogenic shock. Evidence now suggests the opposite: stable patients may safely undergo non-culprit PCI acutely, while cardiogenic shock patients with a clear culprit artery have a dramatic 8% absolute increase in mortality if non-culprit PCI is performed acutely (CULPRIT-SHOCK trial, STEMI or NSTEMI).⁶⁹ Non-culprit PCI increases procedural time and contrast load, leading to more LV volume overload and renal injury and is hazardous in the hemodynamically compromised patient. Also, non-culprit PCI may induce peri-PCI myocardial injury, distal embolization or side branch compromise, unlikely to be tolerated in the tenuous patient.

Outside cardiogenic shock, complete revascularization of non-culprit arteries with stenoses >70%, regardless of the presence of residual symptoms or ischemia, was beneficial and reduced the 3-year risk of future MI, mainly NSTEMI, in comparison to culprit-only PCI, according to the large COMPLETE trial (5.4% vs. 7.9%); of note, mortality was not reduced. Non-culprit PCI was performed during a procedure separate from culprit PCI, within the same hospitalization or up to 45 days after discharge.⁷⁰ Other trials have suggested the safety of non-culprit PCI in the same setting as culprit PCI (PRAMI, Compare-acute) or separately during the same hospitalization (DANAMI-3 PRIMULTI).^71,72 Only COMPLETE has shown a reduction in MI, and thus, non-culprit PCI at a separate setting may be favored, during the same hospitalization (especially if critical stenosis >90%) or soon after it, as long as non-culprit PCI is feasible and the patient is not too sick to tolerate it. Immediate non-culprit PCI may be performed, while accounting for the complexity of PCIs and the total contrast load.

CABG is rarely required acutely in STEMI (~0.2-1%),^62,63 but may be more frequently required in patients with cardiogenic shock and severe left main or three-vessel disease. In fact, in the SHOCK trial, 37% of invasively managed patients were emergently revascularized with CABG (a median of 2.7 hours after randomization, 19 hours after MI).⁷³ Acute CABG may also be required after a failed PCI.

If staged CABG is judged necessary for full revascularization of non-culprit arteries after culprit PCI, it is preferred to wait at least 24 hours, and preferably 3–7 days. CABG mortality is increased in the first 3 days after a large MI.⁷⁴ In patients who developed RV infarct and were not successfully reperfused in the first 6 hours, it is better to delay CABG 4 weeks to let the RV heal (otherwise, there may be severe, intractable RV dilatation upon opening the pericardium during CABG). In a patient with left main or three-vessel disease and RCA-related MI, the RCA is stented and CABG performed 1 month later. If CAD is critical (e.g., > 75% left main stenosis), one may recanalize the RCA with balloon angioplasty and perform CABG sooner, a few days later.