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BACKGROUND: Anatomic complete revascularization (ACR) and functional complete revascularization (FCR) have been associated with reduced death and myocardial infarction (MI) in some prior studies. The impact of complete revascularization (CR) in patients undergoing an invasive (INV) compared with a conservative (CON) management strategy has not been reported. OBJECTIVES: Among patients with chronic coronary disease without prior coronary artery bypass grafting randomized to INV vs CON management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial, we examined the following: 1) the outcomes of ACR and FCR compared with incomplete revascularization; and 2) the potential impact of achieving CR in all INV patients compared with CON management. METHODS: ACR and FCR in the INV group were assessed at an independent core laboratory. Multivariable-adjusted outcomes of CR were examined in INV patients. Inverse probability weighted modeling was then performed to estimate the treatment effect had CR been achieved in all INV patients compared with CON management. RESULTS: ACR and FCR were achieved in 43.4% and 58.4% of 1,824 INV patients. ACR was associated with reduced 4-year rates of cardiovascular death or MI compared with incomplete revascularization. By inverse probability weighted modeling, ACR in all 2,296 INV patients compared with 2,498 CON patients was associated with a lower 4-year rate of cardiovascular death or MI (difference -3.5; 95% CI: -7.2% to 0.0%). In comparison, the event rate difference of cardiovascular death or MI for INV minus CON in the overall ISCHEMIA trial was -2.4%. Results were similar but less pronounced with FCR. CONCLUSIONS: The outcomes of an INV strategy may be improved if CR (especially ACR) is achieved. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).
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Enfermedad de la Arteria CoronariaRESUMEN
Large thrombus burden negatively affects the results of percutaneous coronary intervention(PCI) for acute ST-segment elevation myocardial infarction (STEMI). We investigated theimpact of thrombus burden in patients with STEMI undergoing primary PCI with the meshcoveredMGuard stent (InspireMD Ltd., Tel Aviv, Israel) versus a control bare-metal or drugelutingstent. In 433 patients with STEMI randomized to the MGuard stent versus a controlstent, angiographically visible thrombus was identified in 383 patients (88.5%), with medianthrombus area 30.15 mm2 (22.70, 41.93). Lesions with large thrombus (area > median) weretreated with more frequent use of manual aspiration (80.8% vs 65.8%, p[0.0009) and longer(22.1 5.9 vs 19.4 5.4 mm, p <0.0001) and larger (3.46 0.40 vs 3.29 0.36 mm, p <0.0001)stents. PCI of lesions with large thrombus burden had more thrombotic complications (30.6%vs 15.9%, p [ 0.0007) and reduced angiographic success (80.3% vs 91.1%, p [ 0.003). Inlarge thrombus lesions, the MGuard stent was more effective than control stents in achievingThrombolysis In Myocardial Infarction-3 flow (87.9% vs 74.5%, p [ 0.02) and tended toresult in less slow flow or no reflow (8.8% vs 17.6%, p [ 0.07). ST-segment resolution wasimproved with the MGuard, and clinical outcomes were favorable in both stent groups,regardless of thrombus burden. In conclusion, reperfusion success is reduced after primaryPCI in lesions with large thrombus burden, an outcome that may be modified by the MGuardstent.
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Infarto del Miocardio , Intervención Coronaria Percutánea , StentsRESUMEN
Primary percutaneous coronary intervention (PCI) is therecommended method of reperfusion in patients withST-segment elevation myocardial infarction (STEMI).1However, extended delay from symptom onset to mechanicalreperfusion has a negative impact on clinical outcomes.This may be explained by larger infarct size with morefrequent transmural infarction, larger areas of microvasculardysfunction and myocardial edema, and lower proceduralsuccess.2e5 The longer time to reperfusion may promotelarger and more organized thrombus formation and renderboth pharmacologic and mechanical (aspiration thrombectomy)strategies less effective. It is unknown if this limitationmay be overcome with a novel embolic protection stentdesign geared to reduce distal embolization. The purpose ofthis analysis from the MGuard for Acute ST ElevationReperfusion (MASTER) trial was to evaluate the impact ofdelay to reperfusion on outcomes in patients with STEMIundergoing primary PCI according to the type of stent placed.