الفهرس 
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Abstract
Summary
Introduction.
In patients having acute ST-Segment elevation myocardial infarction STEMI, the preferred intervention strategy is percutaneous coronary intervention PCI. Whether staged PCI (S-PCI) or one-time complete PCI (MV-PCI) is more beneficial and safer in terms of treating the non-culprit vessel during the primary PCI procedure is unclear. Till now the current guidelines recommendations: in 2017 the American College of Cardiology (ACC)/American Heart Association (AHA)/Society for cardiovascular Angiography and Interventions (SCAI); considered multivessel PCI either at the time of primary PCI or as a staged procedure (Class IIb).117 While; in 2018 the ESC/EACTS guidelines considered to be (Class IIa, A).99 and in 2021 ACC/AHA Guidelines considered to be (Class 1, A).102
Aim of the work.
The aim of this work is to assess the in-hospital, mid-term and one year outcome of early complete multi-vessel revascularization versus staged revascularization in the primary PCI for acute STEMI.
Patients and methods.
This study was a prospective non-randomized study performed on one hundred patients referred to the cardiology department at Chest Diseases Hospital in Kuwait state and Beni-Suef University hospital in Egypt. The patients with Acute STEMI and multivessel CAD disease underwent primary PCI.
This study included using two different strategies for treating acute STEMI with multivessel coronary artery lesions (using DES: Drug eluting stents), the primary PCI of the culprit lesion with immediate PCI for the significant non-culprit lesion/s in group I, while in-hospital staged PCI for non-culprit lesion/s after successful primary PCI for the culprit lesion in group II.
Each group included 50 patients.
Inclusion Criteria:
All stable patients with acute STEMI and MV coronary artery disease.
Exclusion Criteria:
1) Any contraindication for antiplatelet therapy as; bleeding disorders including, hematuria, gastrointestinal bleeding or known bleeding tendency either acquired or inherited.
2) Patients with end-stage renal disease on dialysis.
3) Previous myocardial infarction.
4) Previous myocardial revascularization either, percutaneous coronary intervention or CABG.
5) Patients with cardiogenic shock at presentation.
6) Patients with unsuitable anatomy for primary PCI.
7) Severe non ischemic valvular lesions.
8) Life expectancy < 6 months.
9) Patients with high risk coronary artery lesions type C classified according to ACC/AHA guidelines.
Every patient was subjected to:
1) Complete history taking, 12-lead ECG and echocardiography.
2) Coronary interventional technique with; complete revascularization in
group I, and staged revascularization in group II.
3) 1-year follow-up.
a- Clinical follow-up for detecting any major adverse cardiac events
(MACE).
b- Coronary angiography for patients who developed;
Typical ischemic chest pain for evaluation of the previously deployed stent for detection of in-stent re-stenosis or stent thrombosis and the need for culprit (TVR) or non-culprit vessel revascularization.
Results:
The primary endpoints: The Short and long-term MACE: at 3, 6 and 12 months):
There was no significant difference as regard myocardial infarction during the first year follow up period, occurred in 2 patients (4%) in group I vs. 0 patients in group II, with P value = 0.25.
Death, TVR and stent thrombosis during the first year follow up period did not occur in any patient in the whole study.
There was no final significant difference on the requirement of CABG:2 patients (4%) in group I vs. 0 patients in group II, P=0.25.
There was no significant difference, as regard to the MACE at 1 year in spite of numerical safety differences in favor of in-hospital staged PCI 4 patients (8%) in group I vs. 0 patients (0%) in group II , (P= 0. 14).
The secondary endpoints: (The in-hospital MACE and the safety outcomes during the index hospitalization):
The immediate in-hospital angiographic success was (98%) and the achievement of TIMI flow III was (100%) in both groups.
No requirement of in-hospital CABG and no mortality for any patient in both groups. There was no significant difference in the in-hospital myocardial infarction, 1 patient (2%) in group I versus 2 patients (4%) in group II, (P = 0.50). There was no significant difference in the in-hospital culprit lesion revascularization in both groups 1 patient (2%) in group I, and 1 patient (2%) for the group II, (P= 1).
The total composite of in-hospital (MACE); the need for bypass surgery or repeat PCI, acute myocardial infarction or death was not significant. Occurred in 2 patients (4%) in group I and 3 patients (6%) for group II without statistical significant difference in both groups (P=0.50). In-hospital heart failure manifestations (NYHA class IV heart failure) was significantly better in the in-hospital staged PCI group,10 patients (20%) in group I vs. 3 patients (6%) in group II, (P= 0.03).
The contrast-associated acute kidney injury: was better with a statistical significance in the in-hospital staged PCI group, 9 patients (18%) versus 2 patients (4%) in the immediate PCI group, (p=0.03).
The mean procedural time was (69 ± 9.5) minutes in group I vs. (40 ± 0.4) minutes in group II with statistical significant difference (P < 0.001).The mean amount of contrast used in the procedure was (275.1 ± 41.4 ml) in group I vs. (210.1 ± 18.5 ml) in group II, with statistical significant difference (P < 0.001).
Conclusion & Recommendations:
In the treatment of acute ST-segment elevation myocardial infarction with multi-vessel coronary artery lesions, the strategy of: DES implantation (staged PCI) after the primary intervention of the culprit lesion versus (the immediate total revascularization) strategy; yields superior safety, as the immediate total revascularization strategy was associated with significantly longer procedure and fluoroscopy times, higher contrast volumes with acute kidney injury and In-hospital heart failure manifestation (NYHA class IV heart failure), with no final significant difference regarding MACE in spite of numerical (not statistical) safety differences in favor of staged PCI strategy due to the small number of patients included.
Staged PCI (vs. the immediate total revascularization) strategy yields similar efficacy, as the immediate angiographic success was (98%), and the achievement of TIMI flow III was (100%) in both groups with no significant difference as regard angiographic restenosis rate at 1 year.
Recommendations: As shown in this study, the strategy of culprit vessel intervention at the primary PCI followed by in-hospital staged intervention for significant non-culprit lesions seems to be the superior strategy.