European Heart Journal Advance Access originally published online on June 29, 2005
European Heart Journal 2005 26(17):1810-1811; doi:10.1093/eurheartj/ehi404
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Complete myocardial revascularization: between myth and reality: reply
Institute of Cardiology and Center of
Excellence on Aging
‘G. d'Annunzio’ University
San Camillo de Lellis Hospital
via Forlanini 50
66100 Chieti
Italy
Tel: +39 0871 358622
Fax: +39 0871 402817
E-mail address: m.zimarino{at}unich.it
Institute of Cardiology and Center of
Excellence on Aging
‘G. d'Annunzio’ University
San Camillo de Lellis Hospital
via Forlanini 50
66100 Chieti
Italy
In the setting of unstable angina (UA) and non-ST elevation myocardial infarction (NSTEMI), by far, the most beneficial strategy is actually to identify patients at medium-high risk and treat them aggressively with intensive antiplatelet therapy, early angiography, and subsequent myocardial revascularization. This message is shared by most of the recent large-scale clinical trials that have been designed to address this issue.1–3 Deferral of intervention for any reason does not improve the outcome of such patients.4 Assumptions on the completeness of myocardial revascularization may only indirectly be inferred, and no absolute statement can be done in this direction on the pure basis of the prevalence of intervention in the aggressive arm.
In our review, we deliberately did not underline the necessity of a complete revascularization of patients with multi-vessel coronary artery disease (CAD), as the present evidence does not point in this direction. We agree that patients with UA/NSTEMI have several complex non-culprit lesions,5 but this notion cannot be extrapolated to the belief that treatment of all plaques improves prognosis. The angiographic evaluation of non-culprit lesions in UA/NSTEMI patients is often inaccurate. The great advantage deriving from a percutaneous coronary intervention (PCI) strategy is that after the treatment of the culprit lesion, patients may undergo a functional non-invasive evaluation directed to unveil the haemodynamic significance of other lesions, although prediction of the risk of rupture remains elusive. Staged PCI might be the optimal strategy in UA/NSTEMI patients with multi-vessel CAD.6,7 Although it may increase catheterization laboratory occupancy, it could effectively decrease costs avoiding unnecessary treatment of all lesions.
References
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