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doi: 10.1136/hrt.2009.177162
2010 96: 662-667 originally published online September 23, 2009Heart
Luigi Politi, Fabio Sgura, Rosario Rossi, et al.
events during long-term follow-up
myocardial infarction: major adverse cardiac
multi-vessel revascularisation in ST-elevation
A randomised trial of target-vessel versus
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A randomised trial of target-vessel versus
multi-vessel revascularisation in ST-elevation
myocardial infarction: major adverse cardiac events
during long-term follow-up
Luigi Politi, Fabio Sgura, Rosario Rossi, Daniel Monopoli, Elisa Guerri, Chiara Leuzzi,
Francesca Bursi, Giuseppe Massimo Sangiorgi, Maria Grazia Modena
ABSTRACT
Background Few reports described outcomes of
complete compared with infarct-related artery (IRA)-only
revascularisation in patients with ST-elevation myocardial
infarction (STEMI) and multivessel coronary artery
disease (CAD). Moreover, no studies have compared the
simultaneous treatment of non-IRA with the IRA
treatment followed by an elective procedure for the other
lesions (staged revascularisation).
Methods The outcomes of 214 consecutive patients
with STEMI and multivessel CAD undergoing primary
angioplasty were studied. Before the first angioplasty
patients were randomly assigned to three different
strategies: culprit vessel angioplasty-only (COR group);
staged revascularisation (SR group) and simultaneous
treatment of non-IRA (CR group).
Results During a mean follow-up of 2.5 years, 42
(50.0%) patients in the COR group experienced at least
one major adverse cardiac event (MACE), 13 (20.0%) in
the SR group and 15 (23.1%) in the CR group, p<0.001.
Inhospital death, repeat revascularisation and re-
hospitalisation occurred more frequently in the COR
group (all p<0.05), whereas there was no significant
difference in re-infarction among the three groups.
Survival free of MACE was significantly reduced in the
COR group but was similar in the CR and SR groups.
Conclusions Culprit vessel-only angioplasty was
associated with the highest rate of long-term 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.
Primary percutaneous coronary intervention (PCI)
is currently the treatment of choice in patients
with acute ST-segment elevation myocardial
infarction (STEMI). Coronary artery disease (CAD)
is a diffuse process and patients presenting with
a coronary syndrome in 20e40% of cases have
multiple significant coronary lesions, which confer
a substantially increased risk of cardiovascular
morbidity and mortality.
1e3
Contemporary guidelines recommend dilating
only the infarct-related artery (IRA) during the
urgent procedure, leaving the other stenosed vessels
untreated (culprit-only revascularisation) or to
dilate during a second elective procedure (staged
revascularisation). Simultaneous treatment of IRA
and non-IRA is recommended only in patients with
cardiogenic shock.
4 5
However, these guidelines are
based on the results of earlier studies. With
advancing technology and newer antiplatelet drugs,
outcomes have improved even in patients
undergoing multivessel and higher-risk elective
procedures.
6
Yet, few reports have described
outcomes of multivessel compared with IRA-only
revascularisation in patients undergoing urgent
mechanical reperfusion for STEMI,
78
and none
have distinguished simultaneous treatment of non-
IRA from the staged approach. Therefore, the
optimal management of patients with multivessel
disease in this setting remains still unclear.
The aim of this study was to compare long-term
outcomes of three different strategies during
primary PCI in patients with STEMI and
multivessel CAD: culprit vessel-only angioplasty;
angioplasty of IRA followed by an elective
procedure for the treatment of other lesions and
simultaneous treatment of IRA and non-IRA.
METHODS
Study population
We examined patients with STEMI and multivessel
CAD undergoing primary PCI. Between January
2003 and December 2007 in our 24 h catheterisation
laboratory we performed 779 primary PCI, among
which we identified 263 consecutive patients
(33.7%) with multivessel CAD (defined as >70%
diameter stenosis of two or more epicardial coronary
arteries or their major branches by visual estimation).
Included were patients with the presence of
prolonged (more than 30 minutes) chest pain,
started less than 12 h before hospital arrival and ST
elevation of at least 1 mm in two or more
contiguous limb electrocardiographic leads or 2 mm
in precordial leads.
Patients with cardiogenic shock at presentation
(systolic blood pressure #90 mm Hg despite drug
therapy), left main coronary disease ($50% diam-
eter stenosis), previous coronary artery bypass
grafting (CABG) surgery, severe valvular heart
disease and unsuccessful procedures were excluded
from the study. Procedure success was defined as
the achievement of an angiographic residual
stenosis of less than 30% and a thrombolysis in
myocardial infarction (TIMI) flow grade III after
treatment of the culprit lesion. Two hundred and
fourteen patients were eligible and thus represent
the study population.
Before the procedure patients were treated with
aspirin, unfractioned heparin and abciximab bolus
Institute of Cardiology,
Policlinico University Hospital,
Modena, Italy
Correspondence to
Dr Luigi Politi, Institute of
Cardiology, Policlinico University
Hospital, Via del Pozzo 71,
Modena 41100, Italy;
luigi.politi@unimore.it
Accepted 25 August 2009
662 Heart 2010;96:662e667. doi:10.1136/hrt.2009.177162
Acute coronary syndromes
group.bmj.com on May 1, 2010 - Published by heart.bmj.comDownloaded from
followed by 12 h infusion. In addition, the protocol included
a bolus of N-acetylcysteine 1200 mg and hydration with saline
for 12 h after contrast exposure at an infusion rate of 1 ml/kg per
hour. Iodixanol (Visipaque) was used as contrast media in all
patients. Post-PCI medical oral treatment included aspirin,
statins and clopidogrel, unless contraindicated, which was
recommended for 30 days in case of bare metal stent implanta-
tion and for 12 months in case of drug-eluting stents. Signed
informed consent for primary PCI and for the study was
obtained from all patients before the procedure.
Soon after every diagnostic angiography, the eligible patients
were randomly allocated to three different strategies:
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 revascu-
larisation 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.
Before the angioplasty, dedicate software generated a number
(1 for the COR group, 2 for the SR group and 3 for the CR
group), which allowed the operator to allocate each patient in
a specific strategy group. Data were then analysed as intention-
to-treat.
The study protocol conforms to the ethical guidelines of the
1975 Declaration of Helsinki and was approved by the institu-
tion’s human research committee.
Definitions and endpoints
Clinical and procedural data were collected by reviewing hospital
records and angiographic runs stored in DICOM CDs. Left
ventricular ejection fraction (LVEF) was measured by trans-
thoracic echocardiography in all patients soon before the primary
PCI in the catheterisation laboratory by one of the interventional
cardiologists and at discharge by one of the clinical physicians. The
angiographic TIMI flow grade of the infarct artery was estimated
before and after completion of coronary balloon angioplasty
according to four grades of flow, as previously described.
9
We recorded the length of hospitalisation and the occurrence
of contrast-induced nephropathy (CIN) in all patients. CIN was
defined as an absolute increase in serum creatinine values of
0.5 mg/dl or greater or a 25% or greater relative increase from
baseline within 72 h following both primary and elective PCI.
10
Chronic renal failure was defined as baseline estimated creati-
nine clearance of less than 60 ml/minute (according to the
CockrofteGault formula).
11
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 symp-
toms, re-infarction or objective evidence of significant ischaemia
on provocative testing.
12
Among repeat PCI we excluded staged
procedures already scheduled. In the staged group we classified
as repeat revascularisation only unplanned procedures. Follow-
up was obtained by outpatient visits and phone interviews.
Sample size calculation
The sample size has been calculated on the basis of the primary
endpoint (MACE). Given an expected rate of MACE of 17% for
the groups undergoing complete revascularisation (both simul-
taneous and staged) versus 50% for the culprit-only group,
13
aiming for a 0.05
a
and 0.90 power, a total of 123 patients
needed to be enrolled (41 patients per group).
14
This has been
increased in order to take into account potential losses to
follow-up and to power the study.
Statistical analysis
Continuous variables are presented as mean6SD, categorical
variables as percentages. Categorical variables were compared
among groups using the
c
2
test or Fisher’s exact test when
appropriate, whereas continuous variables were compared with
the analysis of variance test. KaplaneMeier curves were used to
represent survival and cumulative incidence of events to the
follow-up. For the endpoint ‘death’patients were censored at
death or 20 December 2008 if alive. For MACE patients were
censored at the date of first MACE or at the end of follow-up.
Follow-up was 100% complete. Cox regression analyses were
used to investigate the univariate and multivariable predictors of
events during the follow-up. Multivariable models for MACE in
follow-up included age, gender and the variables that had p<0.1
at univariate analysis. Data are presented as hazard ratios and
95% CI. All tests were two-sided, a p value less than 0.05 was
considered statistically significant. All analyses were performed
using SPSS software, version 15.0 for Windows.
RESULTS
Baseline characteristics
Among the 263 patients with STEMI and multivessel disease,
we excluded 47 for the following reasons: 21 presented in
cardiogenic shock; six had left main coronary disease; nine had
previous CABG surgery; seven had severe valvular heart disease.
The four patients who experienced an unsuccessful procedure
were included in the randomisation process but not in the
follow-up analysis. We thus included in the follow-up 214
patients with STEMI and multivessel CAD meeting the inclu-
sion criteria. The mean age was 65.2612.2 years, 166 (77.5%)
were men. The COR group included 84 (39.2%) patients, the SR
group 65 (30.4%) patients and the CR group 65 (30.4%) patients.
The elective procedure in the SR group was performed on
average 56.8612.9 days after the primary PCI.
Table 1 shows the distribution of baseline characteristics
among the three groups. For therapy at discharge we excluded
patients who died during hospitalisation. The three groups were
similar for age, gender, risk factors, LVEF, enzymatic infarct size,
location of the STEMI, TIMI flow grade, use of drug-eluting
stents and renal disease, whereas there was a difference in the
frequency of three-vessel coronary disease (more represented in
the SR group). Nitrate therapy was more frequent in the COR
group, whereas the three groups were similar for the other
therapies. The incidence of CIN ranged from 1.5% in the CR
group to 3.6% in the COR group without a significant difference
among groups (p¼0.748). The length of hospital stay was
similar in the three groups (p¼0.348).
Events
After a mean follow-up of 2.561.4 years, 23 (10.7%) patients
died, 16 (7.4%) from cardiac causes. Throughout the follow-up,
70 (32.7%) patients experienced at least one MACE, 42 (50.0%)
in the COR group, 13 (20.0%) in the SR group and 15 (23.1%) in
the CR group, p<0.001. The incidence of inhospital death,
repeat revascularisation and re-hospitalisation was significantly
higher in the COR group (all p<0.05), whereas there was no
significant difference in re-infarction among the three groups.
Two patients (one in the SR group and one in the CR group)
received both a re-PCI and a subsequent CABG. Mortality was
Heart 2010;96:662e667. doi:10.1136/hrt.2009.177162 663
Acute coronary syndromes
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more frequent in the COR group although it did not reach
statistical significance (table 2).
KaplaneMeier analysis showed a significant difference among
the three groups for survival free of MACE and re-PCI (figure 1).
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
(p¼0.815). Similarly, survival free of re-PCI was worse in the
COR group compared with both the CR group (p<0.001) and
the SR group (p¼0.005), whereas it was similar between the CR
and SR groups (p¼0.467). In the SR group seven (10.8%)
patients had symptoms or evidence of ischaemia requiring
unplanned re-PCI, six of these before the scheduled procedure.
The mean time between the first and the unplanned procedure
was 42.3622.8 days.
The COR group showed a tendency for a worse overall
survival compared with the other two groups, without reaching
statistical significance (p¼0.151).
Univariate predictors of MACE
Compared with patients who underwent COR treatment, the
other two strategies had a significantly reduced risk of MACE,
with a 63% lower risk in the SR group (p¼0.003) and a 60%
lower risk in the CR group (p¼0.002) (table 3).
Other significant univariate predictors of MACE were diabetes
mellitus, Killip class, chronic renal failure and CIN.
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 predic-
tors of MACE were COR, chronic renal failure and Killip class
(table 4).
DISCUSSION
The main finding of the present study is that after a mean
follow-up of 2.5 years, in patients with multiple coronary
lesions treated with primary PCI, multivessel revascularisation
had a better outcome than treatment of IRA only. Both the
simultaneous treatment of non-IRA vessels and the staged
approach resulted in a lower risk of MACE compared with the
culprit-only procedure. In particular, patients in the COR group
had a higher risk of repeat unplanned revascularisation, re-
hospitalisation and inhospital death.
According to current guidelines, PCI should be performed only
in IRA, at least in patients without cardiogenic shock.
5
This
recommendation is based on the hypothesis that single-vessel
PCI has a more favourable benefit-to-risk ratio and better
financial implications. Some studies suggest that the more
conservative strategy of treating only the IRA could avoid the
complications arising from longer procedures, such as the larger
Table 1 Baseline characteristics
COR N[84 SR N[65 CR N[65 p Value
Age, years 66.5613.2 64.1611.1 64.5611.7 0.413
Male gender 64 (76.2%) 52 (80.0%) 50 (76.9%) 0.849
Diabetes mellitus 20 (23.8%) 12 (18.5%) 9 (13.8%) 0.305
Hypertension 50 (59.5%) 42 (64.6%) 32 (49.2%) 0.192
LVEF before PCI, % 44.6610.1 45.968.6 45.4610.4 0.718
LVEF at discharge, % 45.4610.3 47.268.3 46.169.9 0.673
Mass CK-MB peak, ng/ml 143.16103.8 150.8692.2 155.9697.6 0.853
Systolic blood pressure before PCI,
mm Hg
136.2630.2 136.2631.4 136.0624.3 0.999
Anterior location of STEMI 35 (41.7%) 28 (43.8%) 31 (47.7%) 0.761
Killip class at admission 1.4860.61 1.4060.70 1.2460.53 0.083
Three-vessel disease 21 (25.0%) 29 (44.6%) 19 (29.2%) 0.033
TIMI flow grade before PCI 0.7661.21 0.8961.21 1.1161.32 0.244
Door-to-balloon time, minutes 63.1627.2 65.7619.4 60.1622.6 0.824
Drug-eluting stent 10 (11.9%) 6 (9.2%) 5 (7.7%) 0.722
Chronic renal failure 24 (29.3%) 16 (24.6%) 17 (26.6%) 0.816
Plasma creatinine before PCI, mg/dl 1.1460.69 1.1360.99 0.9860.27 0.369
CIN 3 (3.6%) 2 (3.1%) 1 (1.5%) 0.748
Length of hospital stay, days 5.362.5 5.463.1 4.862.6 0.348
Therapy at discharge N¼77 N¼65 N¼63
Aspirin 74 (96.1%) 65 (100%) 62 (98.4%) 0.239
Clopidogrel 71 (92.2%) 65 (100%) 61 (96.8%) 0.054
Beta-blockers 62 (80.5.7%) 52 (80.0%) 52 (82.5%) 0.927
Statins 68 (88.3%) 60 (92.3%) 57 (90.5%) 0.724
Nitrates 16 (20.8%) 4 (6.2%) 4 (6.3%) 0.007
ACE inhibitors 48 (62.3%) 38 (58.5%) 35 (55.6%) 0.594
ACE, angiotensin-converting enzyme; CIN, contrast-induced nephropathy; CK-MB, MB isoenzyme of creatine kinase; COR, culprit-only
revascularisation; CR, complete revascularisation; LVEF, left ventricular ejection fraction; PCI, percutaneous coronary intervention; SR,
staged revascularisation; STEMI, ST-elevation myocardial infarction; TIMI, Thrombolysis In Myocardial Infarction.
9
Table 2 Rate of outcomes in the three groups
Outcome COR group SR group CR group p Value
Overall MACE 42 (50.0%) 13 (20.0%) 15 (23.1%) <0.001
Re-PCI 25 (29.8%) 7 (10.8%) 5 (7.7%) <0.001
CABG 3 (3.6%) 2 (3.1%) 2 (3.1%) 0.980
Repeat revascularisation 28 (33.3%) 8 (12.3%) 6 (9.2%) <0.001
Re-hospitalisation 30 (35.7%) 9 (13.8%) 8 (12.3%) <0.001
Re-infarction 7 (8.3%) 4 (6.2%) 2 (3.1%) 0.412
Death 13 (15.5%) 4 (6.2%) 6 (9.2%) 0.170
Cardiac death 10 (11.9%) 2 (3.1%) 4 (6.3%) 0.120
Inhospital death 7 (8.3%) 0 (0%) 2 (3.1%) 0.037
CABG, coronary artery bypass grafting; COR, culprit-only revascularisation; CR, complete
revascularisation; MACE, major adverse cardiac event; PCI, percutaneous coronary
intervention; SR, staged revascularisation.
664 Heart 2010;96:662e667. doi:10.1136/hrt.2009.177162
Acute coronary syndromes
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use of contrast medium with a potentially increased risk of CIN,
the increased administration or radiation, as well as the danger
of ischaemia in non-infarcted myocardial regions.
715
In recent years, with the development of new advanced
devices and the use of platelet glycoprotein IIb/IIIa inhibitors,
the outcome of multivessel PCI has markedly improved.
16 17
Some reports have indicated that the multivessel approach as
safe and cost-effective. Brener et al
18
retrospectively examined
more than 100 000 patients with acute coronary syndromes and
demonstrated a similar incidence of inhospital events between
patients receiving single and multivessel treatment. Ijsselmuiden
et al
6
randomly assigned 219 patients with acute coronary
syndromes to culprit-only versus multivessel revascularisation,
and they found that the multivessel approach had better
outcomes by decreasing the need for further interventions.
To the best of our knowledge the present study is the first
that compares throughout a long follow-up the three most
common strategies during primary PCI in patients with
multivessel disease: culprit vessel-only (COR group); culprit
vessel in an urgent procedure with completion of revascularisa-
tion in another elective procedure (SR group) and complete
revascularisation during the same procedure (CR group). The
three groups were similar for most baseline characteristics and
this strengthens our results. We found that, compared with the
single-vessel approach, multivessel revascularisation is safe and
is associated with a lower risk of MACE at a mean follow-up of
2.5 years. In particular, patients in the SR group had a 63% lower
risk of MACE and patients in the CR group had a 60% lower
risk. This result is attributable mainly to the lower incidence of
inhospital death, re-PCI and re-hospitalisation both in the SR
and CR groups compared with the COR group. Furthermore, we
found that COR was a significant and strong predictor of MACE
even after multivariable adjustment for age, gender, diabetes
mellitus, LVEF before PCI, Killip class, CIN and chronic renal
failure.
Our findings differ from the HELP AMI study,
8
in which in 69
STEMI patients treated with primary PCI the 1-year incidence
of repeat revascularisation was similar in single and multivessel
strategies. Conversely, the present study is in line with a more
recent report by Qarawani et al,
13
which observed in a popula-
tion of 120 patients undergoing primary PCI a lower incidence of
re-PCI among those receiving complete revascularisation during
Figure 1 KaplaneMeier curves describing survival free of major adverse cardiac events (MACE; upper panel), survival free of re-percutaneous
coronary intervention (PCI; middle panel) and overall survival (bottom panel) among the three groups. A solid line indicates the staged revascularisation
(SR) group, a dotted line indicates the complete revascularisation (CR) group, a dashed line indicates the culprit-only revascularisation (COR) group.
Heart 2010;96:662e667. doi:10.1136/hrt.2009.177162 665
Acute coronary syndromes
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a 1-year follow-up. In addition, our data extend to the primary
PCI setting the results Kalarus et al,
19
which showed the nega-
tive effect of incomplete revascularisation in more than 700
patients with myocardial infarction undergoing non-emergent
PCI. A possible explanation for the protective effect of multi-
vessel PCI is that it allows a more complete treatment of other
potentially unstable plaques. Indeed, the inflammatory reaction
arising during acute coronary syndromes and responsible for
plaque instability is not limited to the culprit lesion, but
involves the entire coronary tree.
3
We observed a low incidence of CIN that was similar in the
three groups analysed. Marenzi et al
20
reported a higher rate of
CIN (19%) in 208 patients with STEMI undergoing primary
PCI. The authors attributed this increased risk to the generally
longer procedural time and larger amount of contrast medium
used in urgent procedures. In the present study we used the
same criteria to define CIN, but we implemented new preven-
tive measures for CIN (isosmolar contrast media, periprocedural
hydration with N-acetylcysteine infusion), which have been
shown to reduce the risk of renal complications even in longer
and more complex procedures.
21 22
Previous studies acknowledge as a potential disadvantage of
early complete revascularisation the longer hospital stay with an
increase of costs. In the present study the length of hospital-
isation was similar in the three groups.
Whereas the outcome in the COR group was significantly
worse than in the multivessel approach, we did not find
differences in the CR versus the SR group in terms of MACE or
re-PCI throughout the follow-up.
Our results suggest that the multivessel approach (either with
early complete revascularisation or with a staged procedure) is
safe and possibly less expensive than an incomplete approach by
reducing the probability of further unplanned procedures and
without affecting the length of hospitalisation. We suppose that
multivessel revascularisation could decrease the risks and
discomfort for patients associated with new unscheduled
procedures.
Strengths and limitations
To the best of our knowledge, this is the largest study comparing
the three available strategies during primary PCI for patients
with STEMI and multivessel CAD. Given the relatively recent
enrolment time, all PCI were performed using contemporary
devices and therapies, thus this study provides an up-to-date
picture of the current practice in STEMI. Moreover, the three
groups were fairly homogeneous for most characteristics and
this could strengthen our results.
Possible limitations of the study are the imbalance in the
number of patients in the three groups and the difference in the
presence of three-vessel disease, but these are features of blind
and unrestricted randomisation.
CONCLUSIONS
In a contemporary homogeneous cohort of patients with STEMI
and multivessel CAD treated with primary PCI, COR angio-
plasty 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 multi-
vessel CAD and STEMI.
Acknowledgements The authors would like to thank all the laboratory nurses and
technicians: Chiara Venturelli, Cristina Leonelli, Enrica Melodi, Lina Rosati, Olinda
Rombola
`, Rebecca Simonetti, Rosa Miccoli and Tiziana Damante. Their work has
been fundamental for the realisation of this study.
Competing interests None.
Ethics approval This study was conducted with the approval of the Ethics Commitee
of Policlinico Hospital, Modena, Italy.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES
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Group. Am Heart J 1991;121:1042e9.
2. Jaski BE, Cohen JD, Trausch J, et al. Outcome of urgent percutaneous transluminal
coronary angioplasty in acute myocardial infarction: comparison of single-vessel
versus multivessel coronary artery disease. Am Heart J 1992;124:1427e33.
3. Goldstein JA, Demetriou D, Grines CL, et al. Multiple complex coronary plaques in
patients with acute myocardial infarction. N Engl J Med 2000;343:915e22.
4. Webb JG, Lowe AM, Sanborn TA, et al. Percutaneous coronary intervention for
cardiogenic shock in the SHOCK trial. J Am Coll Cardiol 2003;42:1380e6.
5. Smith SC Jr, Feldman TE, Hirshfeld JW Jr, et al. ACC/AHA/SCAI 2005 Guideline
Update for Percutaneous Coronary Interventiondsummary article: a report of the
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Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for
Percutaneous Coronary Intervention). Circulation 2006;113:156e75.
Table 3 Univariate predictors of MACE
Unadjusted HR 95% CI p Value
COR group (referent) 1
SR vs COR group 0.372 0.198 to 0.699 0.002
CR vs COR group 0.409 0.225 to 0.742 0.003
Age 1.013 0.991 to 1.034 0.253
Male sex 0.914 0.522 to 1.601 0.753
Diabetes mellitus 1.727 1.025 to 2.910 0.040
Hypertension 1.254 0.768 to 2.048 0.366
LVEF before PCI 0.977 0.953 to 1.002 0.068
LVEF at discharge 0.987 0.958 to 1.018 0.412
Anterior STEMI 1.083 0.667 to 1.735 0.738
3 vessel CAD 1.078 0.649 to 1.791 0.771
TIMI flow before PCI 0.875 0.714 to 1.074 0.202
Killip class 1.862 1.331 to 2.605 <0.001
Drug-eluting stent 0.864 0.393 to 1.897 0.715
Chronic renal failure 1.852 1.127 to 3.041 0.015
CIN 3.350 1.342 to 8.364 0.010
CAD, coronary artery disease; CIN, contrast-induced nephropathy; COR, culprit-only
revascularisation; CR, complete revascularisation; HR, hazard ratio; LVEF, left ventricular
ejection fraction; MACE, major adverse cardiac event; PCI, percutaneous coronary
intervention; SR, staged revascularisation; STEMI, ST-elevation myocardial infarction; TIMI,
Thrombolysis In Myocardial Infarction.
Table 4 Multivariable determinants of MACE
Covariates Adjusted HR 95% CI p Value
COR group (referent) 1
SR vs COR group 0.377 0.194 to 0.732 0.004
CR vs COR group 0.495 0.262 to 0.933 0.030
Age 0.991 0.967 to 1.019 0.497
Male gender 1.398 0.714 to 2.739 0.310
Diabetes mellitus 1.606 0.894 to 2.8861 0.113
LVEF before PCI 1.000 0.957 to 1.010 0.976
Killip class 1.718 1.167 to 2.529 0.006
Chronic renal failure 1.926 1.012 to 3.665 0.046
CIN 1.587 0.519 to 4.852 0.418
CIN, contrast-induced nephropathy; COR, culprit-only revascularisation; CR, complete
revascularisation; HR, hazard ratio; LVEF, left ventricular ejection fraction; MACE, major
adverse cardiac event; PCI, percutaneous coronary intervention; SR, staged
revascularisation.
666 Heart 2010;96:662e667. doi:10.1136/hrt.2009.177162
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