Korean Circ J.  2024 Oct;54(10):603-615. 10.4070/kcj.2024.0017.

Impact of Complete Revascularization for Acute Myocardial Infarction In Multivessel Coronary Artery Disease Patients With Diabetes Mellitus

• Kang J
• Park S
• Han M
• Park KW
• Han JK
• Yang HM
• Kang HJ
• Koo BK
• Kim HS

• KMID: 2560643
• DOI: http://doi.org/10.4070/kcj.2024.0017

Abstract

Background and Objectives
The clinical benefits of complete revascularization (CR) in acute myocardial infarction (AMI) patients are unclear. Moreover, the benefit of CR is unknown in AMI with diabetes mellitus (DM) patients. We sought to compare the prognosis of CR and incomplete revascularization (IR) in patients with AMI and multivessel disease, according to the presence of DM.
Methods
A total of 2,150 AMI patients with multivessel coronary artery disease were analyzed. CR was defined based on the angiographic image. The primary endpoint of this study was the patient-oriented composite outcome (POCO) defined as a composite of allcause death, any myocardial infarction, and any revascularization within 3 years.
Results
Overall, 3-year POCO was significantly lower in patients receiving angiographic CR (985 patients, 45.8%) compared with IR (1,165 patients, 54.2%). When divided into subgroups according to the presence of DM, CR reduced 3-year clinical outcomes in the nonDM group but not in the DM group (POCO: 11.7% vs. 23.2%, p<0.001, any revascularization: 7.2% vs. 10.8%, p=0.024 in the non-DM group, POCO: 24.3% vs. 27.8%, p=0.295, any revascularization: 13.3% vs. 11.3%, p=0.448 in the DM group, for CR vs. IR). Multivariate analysis showed that CR significantly reduced 3-year POCO (hazard ratio, 0.52; 95% confidence interval, 0.36–0.75) only in the non-DM group.
Conclusions
In AMI patients with multivessel disease, CR may have less clinical benefit in DM patients than in non-DM patients.

Keyword

Percutaneous coronary intervention; Myocardial infarction; Coronary vessels; Myocardial revascularization; Diabetes mellitus

Figure

• 

  Figure 1 Study population.The ‘Grand DES registry’ is a Korean Nationwide prospective registry, including the EXCELLENT registry, HOST-PRIME registry, HOST-RESOLINTE registry, RESOLUTE-Korea registry, and the HOST-BIOLIMUS registry. Out of the total 17,286 patients, 5,166 patients were AMI patients, and after excluding patients with a single vessel disease, patients with a previous CABG history, and those with a poor angiographic image, 2,150 patients were analyzed.AMI = acute myocardial infarction; CABG = coronary artery bypass grafting; DM = diabetes mellitus.

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  Figure 2 Cumulative Incidence of POCO during the 3-year follow-up period, according to the completeness of revascularization.The survival curve of 3-year POCO according to CR. Overall, CR had a beneficial impact on 3-year POCO by an HR of 0.70 (95% CI, 0.54–0.91; p=0.008). Moreover, the 3-year POCO was significantly more common in those with an SS-based IR (POCO: 18.3% vs. 27.4%, p<0.001, in the SS-based CR vs. SS-based IR respectively).CR = complete revascularization; HR = hazard ratio; IR = incomplete revascularization; POCO = patient-oriented composite outcome; rSS = residual SYNTAX score; SS = SYNTAX score.

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  Figure 3 Cumulative Incidence of POCO during the 3-year follow-up period, according to the presence of DM and the completeness of revascularization.In the subgroup according to the presence of DM, CR reduced 3-year POCO only in the non-DM group (HR, 0.52; 95% CI, 0.36–0.75; p<0.001) The beneficial impact of SS-based CR was also only shown in the non-DM group (HR, 0.61; 95% CI, 0.45–0.83; p=0.001), while the effect was neutralized in the DM group.CR = complete revascularization; DM = diabetes mellitus; HR = hazard ratio; IR = incomplete revascularization; POCO = patient-oriented composite outcome; rSS = residual SYNTAX score.

Reference

1. Ertelt K, Brener SJ, Mehran R, Ben-Yehuda O, McAndrew T, Stone GW. Comparison of outcomes and prognosis of patients with versus without newly diagnosed diabetes mellitus after primary percutaneous coronary intervention for ST-elevation myocardial infarction (the HORIZONS-AMI study). Am J Cardiol. 2017; 119:1917–1923. PMID: 28427734.

2. Park S, Park SJ, Park DW. Percutaneous coronary intervention versus coronary artery bypass grafting for revascularization of left main coronary artery disease. Korean Circ J. 2023; 53:113–133. PMID: 36914602.

3. Chichareon P, Modolo R, Kogame N, et al. Association of diabetes with outcomes in patients undergoing contemporary percutaneous coronary intervention: pre-specified subgroup analysis from the randomized GLOBAL LEADERS study. Atherosclerosis. 2020; 295:45–53. PMID: 32006758.

4. Harding JL, Pavkov ME, Magliano DJ, Shaw JE, Gregg EW. Global trends in diabetes complications: a review of current evidence. Diabetologia. 2019; 62:3–16. PMID: 30171279.

5. Rawshani A, Sattar N, Franzén S, et al. Excess mortality and cardiovascular disease in young adults with type 1 diabetes in relation to age at onset: a nationwide, register-based cohort study. Lancet. 2018; 392:477–486. PMID: 30129464.

6. Wald DS, Morris JK, Wald NJ, et al. Randomized trial of preventive angioplasty in myocardial infarction. N Engl J Med. 2013; 369:1115–1123. PMID: 23991625.

7. Gershlick AH, Khan JN, Kelly DJ, et al. 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; 65:963–972. PMID: 25766941.

8. Engstrøm T, Kelbæk H, Helqvist S, et al. 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; 386:665–671. PMID: 26347918.

9. Smits PC, Abdel-Wahab M, Neumann FJ, et al. Fractional flow reserve-guided multivessel angioplasty in myocardial infarction. N Engl J Med. 2017; 376:1234–1244. PMID: 28317428.

10. Shishehbor MH, Lauer MS, Singh IM, et al. In unstable angina or non-ST-segment acute coronary syndrome, should patients with multivessel coronary artery disease undergo multivessel or culprit-only stenting? J Am Coll Cardiol. 2007; 49:849–854. PMID: 17320742.

11. Rathod KS, Koganti S, Jain AK, et al. Complete versus culprit-only lesion intervention in patients with acute coronary syndromes. J Am Coll Cardiol. 2018; 72:1989–1999. PMID: 30336821.

12. Kang J, Park KW, Han JK, et al. Usefulness of the baseline syntax score to predict 3-year outcome after complete revascularization by percutaneous coronary intervention. Am J Cardiol. 2016; 118:641–646. PMID: 27394412.

13. Farooq V, Serruys PW, Bourantas CV, et al. Quantification of incomplete revascularization and its association with five-year mortality in the synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) trial validation of the residual SYNTAX score. Circulation. 2013; 128:141–151. PMID: 23766350.

14. Hashimoto Y, Yasunaga H. Theory and practice of propensity score analysis. Ann Clin Epidemiol. 2022; 4:101–109. PMID: 38505253.

15. Généreux P, Palmerini T, Caixeta A, et al. Quantification and impact of untreated coronary artery disease after percutaneous coronary intervention: the residual SYNTAX (synergy between PCI with taxus and cardiac surgery) score. J Am Coll Cardiol. 2012; 59:2165–2174. PMID: 22483327.

16. Smith SC Jr, Faxon D, Cascio W, et al. Prevention conference VI: diabetes and cardiovascular disease: writing group VI: revascularization in diabetic patients. Circulation. 2002; 105:e165–e169. PMID: 11994268.

17. Farkouh ME, Domanski M, Sleeper LA, et al. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med. 2012; 367:2375–2384. PMID: 23121323.

18. Kang J, Park KW, Lee MS, et al. The natural course of nonculprit coronary artery lesions; analysis by serial quantitative coronary angiography. BMC Cardiovasc Disord. 2018; 18:130. PMID: 29954346.

19. Cui K, Lyu S, Liu H, et al. Staged complete revascularization or culprit-only percutaneous coronary intervention for multivessel coronary artery disease in patients with ST-segment elevation myocardial infarction and diabetes. Cardiovasc Diabetol. 2019; 18:119. PMID: 31530274.

20. Hannan EL, Wu C, Walford G, et al. Incomplete revascularization in the era of drug-eluting stents: impact on adverse outcomes. JACC Cardiovasc Interv. 2009; 2:17–25. PMID: 19463393.

21. Mehta SR, Wood DA, Storey RF, et al. Complete revascularization with multivessel PCI for myocardial infarction. N Engl J Med. 2019; 381:1411–1421. PMID: 31475795.

22. Choi IJ, Park HJ, Seo SM, et al. Predictors of early and late target lesion revascularization after drug-eluting stent implantation. J Interv Cardiol. 2013; 26:137–144. PMID: 23163343.

23. Machecourt J, Danchin N, Lablanche JM, et al. Risk factors for stent thrombosis after implantation of sirolimus-eluting stents in diabetic and nondiabetic patients: the EVASTENT matched-cohort registry. J Am Coll Cardiol. 2007; 50:501–508. PMID: 17678732.