Evaluación con tomografía de coherencia óptica de las lesiones no culpables en pacientes con síndrome coronario con elevación del segmento ST

Tesis inédita de la Universidad Complutense de Madrid, Facultad de Medicina, leída el 21-09-2022Primary percutaneous coronary intervention (PCI) is the preferred method of reperfusion for patients with ST-segment elevation myocardial infarction (STEMI) (1-4). These patients often have multivessel coronary artery disease, with additional angiographically significant lesions in locations separate from that of the culprit lesion that caused the acute event (5). Whether to routinely revascularize these non-culprit lesions or to manage them conservatively with guideline based medical therapy alone is a common dilemma (6-8). Non-culprit lesions, which are usually discovered incidentally at the time of primary PCI, may represent stable coronary artery plaques, for which additional revascularization may not offer additional benefit (9). However, if non-culprit lesions have morphologic features consistent with unstable plaques, which confer an increased risk of future cardiovascular events, there may be a benefit of routine non-culprit-lesion PCI (10, 11)...La angioplastia primaria es el método preferido de reperfusión para pacientes con sindrome coronario agudo con elevación del segmento ST (1-4). Estos pacientes usualmente tienen enfermedad coronaria multivaso, con lesiones angiográficamente significativas en segmentos lejanos a la lesión culpable que causo el evento primario (5). Existe un dilema acerca de si tratar estas lesiones no culpables con revascularización rutinaria o manejarlas conservadoramente solo con terapia medica óptima (6-8). Las lesiones no culpables que se descubren incidentalmente al momento de la angioplastia primaria, pueden representar placas coronarias estables para las cuales revascularización adicional no ofrece beneficio (9). Sin embargo, si las lesiones no culpables tienen características morfológicas consistentes con placas inestables que confieren un riesgo incrementado de eventos cardiovasculares futuros; puede haber un beneficio considerando intervencionismo rutinario (10, 11)...Fac. de MedicinaTRUEunpu

Complete revascularization with multivessel PCI for myocardial infarction

BACKGROUND In patients with ST-segment elevation myocardial infarction (STEMI), percutaneous coronary intervention (PCI) of the culprit lesion reduces the risk of cardiovascular death or myocardial infarction. Whether PCI of nonculprit lesions further reduces the risk of such events is unclear. METHODS We randomly assigned patients with STEMI and multivessel coronary artery disease who had undergone successful culprit-lesion PCI to a strategy of either complete revascularization with PCI of angiographically significant nonculprit lesions or no further revascularization. Randomization was stratified according to the intended timing of nonculprit-lesion PCI (either during or after the index hospitalization). The first coprimary outcome was the composite of cardiovascular death or myocardial infarction; the second coprimary outcome was the composite of cardiovascular death, myocardial infarction, or ischemia-driven revascularization. RESULTS At a median follow-up of 3 years, the first coprimary outcome had occurred in 158 of the 2016 patients (7.8%) in the complete-revascularization group as compared with 213 of the 2025 patients (10.5%) in the culprit-lesion-only PCI group (hazard ratio, 0.74; 95% confidence interval [CI], 0.60 to 0.91; P=0.004). The second coprimary outcome had occurred in 179 patients (8.9%) in the complete-revascularization group as compared with 339 patients (16.7%) in the culprit-lesion-only PCI group (hazard ratio, 0.51; 95% CI, 0.43 to 0.61; P<0.001). For both coprimary outcomes, the benefit of complete revascularization was consistently observed regardless of the intended timing of nonculprit-lesion PCI (P=0.62 and P=0.27 for interaction for the first and second coprimary outcomes, respectively). CONCLUSIONS Among patients with STEMI and multivessel coronary artery disease, complete revascularization was superior to culprit-lesion-only PCI in reducing the risk of cardiovascular death or myocardial infarction, as well as the risk of cardiovascular death, myocardial infarction, or ischemia-driven revascularization. (Funded by the Canadian Institutes of Health Research and others; COMPLETE ClinicalTrials.gov number, NCT01740479. opens in new tab.

Lesión culpable: ¿qué hacer con ella? ¿Es la intervención necesaria en todos los casos?

Paciente de sexo masculino, de 55 años de edad, con antecedente de hipercolesterolemia, previamente asintomático, quien consultó a un hospital regional con un infarto agudo de miocardio con elevación del segmento ST (IAMCEST) de pared inferior