European Heart Journal Advance Access originally published online on June 29, 2005
European Heart Journal 2005 26(17):1809-1810; doi:10.1093/eurheartj/ehi403
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Complete myocardial revascularization: between myth and reality
Thoraxcenter
Erasmus MC
Room Bd 412
Dr Molewaterplein 40
Rotterdam
The Netherlands and
University of Ferrara
Ferrara
Italy
Tel: +31 10 4635260
Fax: +31 10 4369154
E-mail address: vlgmrc{at}unife.it
Department of Cardiology
AZ Middelheim
Antwerp
Belgium
Interventional Cardiology Unit
S. Raffaele Hospital
Milan
Italy
We read with great interest the article by Zimarino et al.1 focusing on the complex issue of complete vs. incomplete myocardial revascularization in patients submitted to percutaneous or surgical coronary intervention. We believe that the authors correctly pointed out some caveats of available literature in this regard, resulting mainly from the lack of prospective randomized investigation specifically designed to address this controversial topic. However, the authors failed to acknowledge that the benefit of early intervention when compared with the conservative approach in patients with non-ST segment elevation acute coronary syndrome (NSTEACS) known to be at medium or high-risk for future cardiovascular events, as mainly supported by the results of FRISC II,2 TACTICS-TIMI 18,3 and RITA 34 trials, was obtained following a complete revascularization strategy, either accomplished through percutaneous or surgical approach, depending on coronary anatomy. In fact, in all three trials supporting the benefit of invasive strategy vs. conservative strategy, independently from the possibility to identify and treat the culprit lesion, an aggressive revascularization to all coronary segments presenting with significant (>70% at visual estimation) stenosis was protocol-mandated. The relatively high number of patients who received coronary artery bypass grafting (CABG) at 1 year, among those in whom myocardial revascularization was found to be feasible and clinically indicated in the invasive arm of these trials (50% in FRISC II, 34% in TACTICS-TIMI 18, and 37% in RITA 3), may also indirectly confirm that a multivessel intervention was often accomplished. This is clearly more in line with a complete revascularization strategy rather than a culprit lesion-oriented approach. Yet, it is noteworthy that in the FRISC II and TACTICS trials, despite the fact that the majority of the surgical procedures were performed in patients with left main or multivessel disease early after infarction (<7 days), CABG was associated with a low-risk of mortality (
2%).2,3
Thus, whether early intervention is undertaken in patients with NSTEACS, as currently recommended by ACC/AHA5 and ESC guidelines,6 any attempt to pursuit a complete revascularization should be thoroughly carried out, well beyond and independently from the possibility to identify and treat the culprit lesion. Indeed, complete revascularization in this setting might be beneficial due to the deleterious progression of unstable plaques otherwise left untreated in the non-culprit vessel(s).7 The failure of current guidelines to address the issue of adequacy of coronary revascularization in patients affected by NSTEACS should be regarded as a potential source of incomprehension, and a position statement in this regard in the upcoming guidelines updates seems to be highly warranted.
References
- Zimarino M, Calafiore AM, de Caterina R. Complete myocardial revascularization: between myth and reality. Eur Heart J Published online ahead of print April 11, 2005, doi:10.1093/eurheartj/ehi249.
- Wallentin L, Lagerqvist B, Husted S, Kontny F, Stahle E, Swahn E. Outcome at 1 year after an invasive compared with a non-invasive strategy in unstable coronary-artery disease: the FRISC II invasive randomised trial. FRISC II Investigators. Fast revascularisation during instability in coronary artery disease. Lancet 2000;356:9–16.[CrossRef][Web of Science][Medline]
- Cannon CP, Weintraub WS, Demopoulos LA, Vicari R, Frey MJ, Lakkis N, Neumann FJ, Robertson DH, deLucca PT, DiBattiste PM, Gibson CM, Braunwald E. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001;344:1879–1887.
[Abstract/Free Full Text] - Fox KA, Poole-Wilson PA, Henderson RA, Clayton TC, Chamberlain DA, Shaw TR, Wheatley DJ, Pocock SJ. Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial. Randomized Intervention Trial of Unstable Angina. Lancet 2002;360: 743–751.[CrossRef][Web of Science][Medline]
- Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, Jones RH, Kereiakes D, Kupersmith J, Levin TN, Pepine CJ, Schaeffer JW, Smith EE III, Steward DE, Theroux P, Gibbons RJ, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Smith SC Jr. ACC/AHA guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction—2002: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). Circulation 2002;106:1893–1900.
[Free Full Text] - Bertrand ME, Simoons ML, Fox KA, Wallentin LC, Hamm CW, McFadden E, de Feyter PJ, Specchia G, Ruzyllo W. Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2002;23:1809–1840.
[Free Full Text] - Goldstein JA, Demetriou D, Grines CL, Pica M, Shoukfeh M, O'Neill WW. Multiple complex coronary plaques in patients with acute myocardial infarction. N Engl J Med 2000;343:915–922.
[Abstract/Free Full Text]
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