Abstract
Among patients with stable ischemic heart disease (SIHD), multivessel disease (MVD) is not uncommon. Moreover, a greater number of vessel stenosis or occlusions sequentially portends a worse prognosis. The optimal treatment for SIHD is a topic of ongoing debate, and a number of important clinical characteristics must be considered prior to deciding on a management strategy. The treatment goals in patients with MVD are to: (1) improve survival and/or (2) relieve symptom burden. Approximately 50% of patients suffering an ST-elevation myocardial infarction (STEMI) have significant MVD, or non-culprit lesions. These patients have worse outcomes due to higher mortality and increased risk of recurrent MI when compared with patients with single-vessel disease. The recommendations for culprit-only PCI versus complete or staged revascularization in the setting of STEMI are dynamic, and have been an ongoing area of controversy, in large part secondary to the lack of adequately powered trials to assess important clinical endpoints. Based on the current literature and guidelines, in the case of STEMI with evidence of concomitant severe non-culprit lesions, there are multiple approaches available to the interventional cardiologist.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Emond M, Mock MB, Davis KB, et al. Long-term survival of medically treated patients in the Coronary Artery Surgery Study (CASS) Registry. Circulation. 1994;90(6):2645–57.
Iqbal J, Zhang YJ, Holmes DR, et al. Optimal medical therapy improves clinical outcomes in patients undergoing revascularization with percutaneous coronary intervention or coronary artery bypass grafting: insights from the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial at the 5-year follow-up. Circulation. 2015;131(14):1269–77.
Task Force M, Montalescot G, Sechtem U, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949–3003.
Riley RF, Don CW, Powell W, Maynard C, Dean LS. Trends in coronary revascularization in the United States from 2001 to 2009: recent declines in percutaneous coronary intervention volumes. Circ Cardiovasc Qual Outcomes. 2011;4(2):193–7.
Boden WE, O’Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356(15):1503–16.
Weintraub WS, Spertus JA, Kolm P, et al. Effect of PCI on quality of life in patients with stable coronary disease. N Engl J Med. 2008;359(7):677–87.
Group BDS, Frye RL, August P, et al. A randomized trial of therapies for type 2 diabetes and coronary artery disease. N Engl J Med. 2009;360(24):2503–515.
Dagenais GR, Lu J, Faxon DP, et al. Effects of optimal medical treatment with or without coronary revascularization on angina and subsequent revascularizations in patients with type 2 diabetes mellitus and stable ischemic heart disease. Circulation. 2011;123(14):1492–500.
Fihn SD, Gardin JM, Abrams J, et al. ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2012;60(24):e44–e164.
De Bruyne B, Pijls NH, Kalesan B, et al. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med. 2012;367(11):991–1001.
Velazquez EJ, Lee KL, Deja MA, et al. Coronary-artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med. 2011;364(17):1607–16.
Velazquez EJ, Lee KL, Jones RH, et al. Coronary-artery bypass surgery in patients with ischemic cardiomyopathy. N Engl J Med. 2016;374(16):1511–20.
Pursnani S, Korley F, Gopaul R, et al. Percutaneous coronary intervention versus optimal medical therapy in stable coronary artery disease: a systematic review and meta-analysis of randomized clinical trials. Circ Cardiovasc Interv. 2012;5(4):476–90.
Bangalore S, Pursnani S, Kumar S, Bagos PG. Percutaneous coronary intervention versus optimal medical therapy for prevention of spontaneous myocardial infarction in subjects with stable ischemic heart disease. Circulation. 2013;127(7):769–81.
Daemen J, Boersma E, Flather M, et al. Long-term safety and efficacy of percutaneous coronary intervention with stenting and coronary artery bypass surgery for multivessel coronary artery disease: a meta-analysis with 5-year patient-level data from the ARTS, ERACI-II, MASS-II, and SoS trials. Circulation. 2008;118(11):1146–54.
Bangalore S. Applicability of the COURAGE, BARI 2D, and FREEDOM trials to contemporary practice. J Am Coll Cardiol. 2016;68(10):996–8.
Farkouh ME, Domanski M, Sleeper LA, et al. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med. 2012;367(25):2375–84.
Kaul U, Bangalore S, Seth A, et al. Paclitaxel-eluting versus Everolimus-eluting coronary stents in diabetes. N Engl J Med. 2015;373(18):1709–19.
Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360(10):961–72.
Park SJ, Ahn JM, Kim YH, et al. Trial of Everolimus-eluting stents or bypass surgery for coronary disease. N Engl J Med. 2015;372(13):1204–12.
Bangalore S, Toklu B, Feit F. Outcomes with coronary artery bypass graft surgery versus percutaneous coronary intervention for patients with diabetes mellitus: can newer generation drug-eluting stents bridge the gap? Circ Cardiovasc Interv. 2014;7(4):518–25.
Bangalore S, Guo Y, Samadashvili Z, Blecker S, Xu J, Hannan EL. Everolimus-eluting stents or bypass surgery for multivessel coronary disease. N Engl J Med. 2015;372(13):1213–22.
Bangalore S, Guo Y, Samadashvili Z, Blecker S, Xu J, Hannan EL. Everolimus eluting stents versus coronary artery bypass graft surgery for patients with diabetes mellitus and multivessel disease. Circ Cardiovasc Interv. 2015;8(7):e002626.
Bangalore S, Guo Y, Samadashvili Z, Blecker S, Hannan EL. Revascularization in patients with multivessel coronary artery disease and severe left ventricular systolic dysfunction: everolimus-eluting stents versus coronary artery bypass graft surgery. Circulation. 2016;133(22):2132–40.
Head SJ, Kaul S, Mack MJ, et al. The rationale for Heart Team decision-making for patients with stable, complex coronary artery disease. Eur Heart J. 2013;34(32):2510–8.
Kolh P, Windecker S, Alfonso F, et al. ESC/EACTS Guidelines on myocardial revascularization: the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg. 2014;46(4):517–92.
Feit F, Brooks MM, Sopko G, et al. Long-term clinical outcome in the Bypass Angioplasty Revascularization Investigation Registry: comparison with the randomized trial. BARI Investigators. Circulation. 2000;101(24):2795–802.
Shahian DM, O’Brien SM, Filardo G, et al. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 3—valve plus coronary artery bypass grafting surgery. Ann Thorac Surg. 2009;88(1 Suppl):S43–62.
Nashef SA, Sharples LD, Roques F, Lockowandt U. EuroSCORE II and the art and science of risk modelling. Eur J Cardiothorac Surg. 2013;43(4):695–6.
Peterson ED, Dai D, DeLong ER, et al. Contemporary mortality risk prediction for percutaneous coronary intervention: results from 588,398 procedures in the National Cardiovascular Data Registry. J Am Coll Cardiol. 2010;55(18):1923–32.
Wykrzykowska JJ, Garg S, Onuma Y, et al. Value of age, creatinine, and ejection fraction (ACEF score) in assessing risk in patients undergoing percutaneous coronary interventions in the ‘All-Comers’ LEADERS trial. Circ Cardiovasc Interv. 2011;4(1):47–56.
Park DW, Clare RM, Schulte PJ, Pieper KS, Shaw LK, Califf RM, Ohman EM, Van de Werf F, Hirji S, Harrington RA, Armstrong PW, Granger CB, Jeong MH, Patel MR. Extent, location, and clinical significance of non-infarct-related coronary artery disease among patients with ST-elevation myocardial infarction. JAMA. 2014;312:2019–27.
van der Schaaf RJ, Timmer JR, Ottervanger JP, Hoorntje JC, de Boer MJ, Suryapranata H, Zijlstra F, Dambrink JH. Long-term impact of multivessel disease on cause-specific mortality after ST elevation myocardial infarction treated with reperfusion therapy. Heart. 2006;92:1760–3.
Sorajja P, Gersh BJ, Cox DA, McLaughlin MG, Zimetbaum P, Costantini C, Stuckey T, Tcheng JE, Mehran R, Lansky AJ, Grines CL, Stone GW. Impact of multivessel disease on reperfusion success and clinical outcomes in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction. Eur Heart J. 2007;28:1709–16.
Bangalore S, Faxon D. Coronary intervention in patients with acute coronary syndrome: does every culprit lesion require revascularization? Curr Cardiol Rep. 2010;12:330–7.
Goldstein JA, Demetriou D, Grines CL, Pica M, Shoukfeh M, O’Neill WW. Multiple complex coronary plaques in patients with acute myocardial infarction. N Engl J Med. 2000;343:915–22.
Corpus RA, House JA, Marso SP, Grantham JA, Huber KC Jr, Laster SB, Johnson WL, Daniels WC, Barth CW, Giorgi LV, Rutherford BD. Multivessel percutaneous coronary intervention in patients with multivessel disease and acute myocardial infarction. Am Heart J. 2004;148:493–500.
Muller DW, Topol EJ, Ellis SG, Sigmon KN, Lee K, Califf RM. Multivessel coronary artery disease: a key predictor of short-term prognosis after reperfusion therapy for acute myocardial infarction. Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) Study Group. Am Heart J. 1991;121:1042–9.
Gibson CM, Ryan KA, Murphy SA, Mesley R, Marble SJ, Giugliano RP, Cannon CP, Antman EM, Braunwald E. Impaired coronary blood flow in nonculprit arteries in the setting of acute myocardial infarction. The TIMI Study Group Thrombolysis in myocardial infarction. J Am Coll Cardiol. 1999;34:974–82.
Ochala A, Smolka GA, Wojakowski W, Dudek D, Dziewierz A, Krolikowski Z, Gasior Z, Tendera M. The function of the left ventricle after complete multivessel one-stage percutaneous coronary intervention in patients with acute myocardial infarction. J Invasive Cardiol. 2004;16:699–702.
Bangalore S, Toklu B, Wetterslev J. Complete versus culprit-only revascularization for ST-segment-elevation myocardial infarction and multivessel disease: a meta-analysis and trial sequential analysis of randomized trials. Circ Cardiovasc Interv. 2015;8:e002142.
Gershlick AH, Khan JN, Kelly DJ, Greenwood JP, Sasikaran T, Curzen N, Blackman DJ, Dalby M, Fairbrother KL, Banya W, Wang D, Flather M, Hetherington SL, Kelion AD, Talwar S, Gunning M, Hall R, Swanton H, McCann GP. Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel disease: the CvLPRIT trial. J Am Coll Cardiol. 2015;65:963–72.
Dambrink JH, Debrauwere JP, van ‘t Hof AW, Ottervanger JP, Gosselink AT, Hoorntje JC, de Boer MJ, Suryapranata H. Non-culprit lesions detected during primary PCI: treat invasively or follow the guidelines? EuroIntervention. 2010;5:968–75.
Di Mario C, Mara S, Flavio A, Imad S, Antonio M, Anna P, Emanuela P, Stefano DS, Angelo R, Stefania C, Anna F, Carmelo C, Antonio C, Monzini N, Bonardi MA. Single vs multivessel treatment during primary angioplasty: results of the multicentre randomised HEpacoat for cuLPrit or multivessel stenting for Acute Myocardial Infarction (HELP AMI) Study. Int J Cardiovasc Interv. 2004;6:128–33.
Politi L, Sgura F, Rossi R, Monopoli D, Guerri E, Leuzzi C, Bursi F, Sangiorgi GM, Modena MG. A randomised trial of target-vessel versus multi-vessel revascularisation in ST-elevation myocardial infarction: major adverse cardiac events during long-term follow-up. Heart. 2010;96:662–7.
Wald DS, Morris JK, Wald NJ, Chase AJ, Edwards RJ, Hughes LO, Berry C, Oldroyd KG, Investigators P. Randomized trial of preventive angioplasty in myocardial infarction. N Engl J Med. 2013;369:1115–23.
Engstrom T, Kelbaek H, Helqvist S, Hofsten DE, Klovgaard L, Holmvang L, Jorgensen E, Pedersen F, Saunamaki K, Clemmensen P, De Backer O, Ravkilde J, Tilsted HH, Villadsen AB, Aaroe J, Jensen SE, Raungaard B, Kober L, Investigators D-P. Complete revascularisation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multivessel disease (DANAMI-3-PRIMULTI): an open-label, randomised controlled trial. Lancet. 2015;386:665–71.
Hlinomaz O. Multivessel coronary disease diagnosed at the time of primary PCI for STEMI: complete revascularization versus conservative strategy: the PRAGUE 13 trial. EuroPCR, May 19, 2015; Paris, France.
Bainey KR, Welsh RC, Toklu B, Bangalore S. Complete vs culprit-only percutaneous coronary intervention in STEMI with multivessel disease: a meta-analysis and trial sequential analysis of randomized trials. Can J Cardiol. 2016;32:1542–51.
O’Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, De Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX, Anderson JL, Jacobs AK, Halperin JL, Albert NM, Brindis RG, Creager MA, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Kushner FG, Ohman EM, Stevenson WG, Yancy CW, American College of Emergency Physicians, Society for Cardiovascular Angiography and Interventions. ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61:e78–140.
Toma M, Buller CE, Westerhout CM, Fu Y, O’Neill WW, Holmes DR Jr, Hamm CW, Granger CB, Armstrong PW, APEX AMI Investigators. Non-culprit coronary artery percutaneous coronary intervention during acute ST-segment elevation myocardial infarction: insights from the APEX-AMI trial. Eur Heart J. 2010;31:1701–7.
Hannan EL, Samadashvili Z, Walford G, Holmes DR Jr, Jacobs AK, Stamato NJ, Venditti FJ, Sharma S, King SB 3rd. Culprit vessel percutaneous coronary intervention versus multivessel and staged percutaneous coronary intervention for ST-segment elevation myocardial infarction patients with multivessel disease. JACC Cardiovasc Interv. 2010;3:22–31.
Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Ting HH, O’Gara PT, Kushner FG, Ascheim DD, Brindis RG, Casey DE Jr, Chung MK, de Lemos JA, Diercks DB, Fang JC, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. J Am Coll Cardiol. 2016;67:1235–50.
Kornowski R, Mehran R, Dangas G, Nikolsky E, Assali A, Claessen BE, Gersh BJ, Wong SC, Witzenbichler B, Guagliumi G, Dudek D, Fahy M, Lansky AJ, Stone GW, Investigators H-AT. Prognostic impact of staged versus “one-time” multivessel percutaneous intervention in acute myocardial infarction: analysis from the HORIZONS-AMI (harmonizing outcomes with revascularization and stents in acute myocardial infarction) trial. J Am Coll Cardiol. 2011;58:704–11.
Vlaar PJ, Mahmoud KD, Holmes DR Jr, van Valkenhoef G, Hillege HL, van der Horst IC, Zijlstra F, de Smet BJ. Culprit vessel only versus multivessel and staged percutaneous coronary intervention for multivessel disease in patients presenting with ST-segment elevation myocardial infarction: a pairwise and network meta-analysis. J Am Coll Cardiol. 2011;58:692–703.
Tonino PA, De Bruyne B, Pijls NH, Siebert U, Ikeno F, van’ t Veer M, Klauss V, Manoharan G, Engstrom T, Oldroyd KG, Ver Lee PN, MacCarthy PA, Fearon WF, Investigators FS. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med. 2009;360:213–24.
Author information
Authors and Affiliations
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2018 Springer International Publishing AG, part of Springer Nature
About this chapter
Cite this chapter
Owlia, M., Bangalore, S. (2018). Multivessel Coronary Artery Disease. In: Myat, A., Clarke, S., Curzen, N., Windecker, S., Gurbel, P.A. (eds) The Interventional Cardiology Training Manual. Springer, Cham. https://doi.org/10.1007/978-3-319-71635-0_29
Download citation
DOI: https://doi.org/10.1007/978-3-319-71635-0_29
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-71633-6
Online ISBN: 978-3-319-71635-0
eBook Packages: MedicineMedicine (R0)