SLIDE 1 Speaker’s name: Thomas Cuisset, MD, PhD X I have the following potential conflicts of interest to report: x Consulting: Astra Zeneca, Daiichi Sankyo, Eli Lilly, Medicines Company ❒ Employment in industry ❒ Stockholder of a healthcare company ❒ Owner of a healthcare company x Others: Lecture Fee
Abbott Vascular, Astra Zeneca, Biotronik, Boston Scientific, Cordis, Daichi Sankyo, Edwards, Eli Lilly, Hexacath, Iroko Cardio, Medtronic, Servier , Terumo
❒ I do not have any potential conflict of interest
SLIDE 2
Thomas Cuisset , CHU TIMONE, Marseille, FR High Tech, Janvier 2018
STEMI et Patient Pluritronculaire
SLIDE 3
Management of MVD in STEMI
About 40-50% of STEMI patients Impaired prognosis for both short and long term Very different patients/anatomies in the same ‘box’ Optimal management still ‘controversial’
SLIDE 4
Options for MVD management in STEMI
SLIDE 5 Data before recent studies Meta-analysis
Vlaar et al, JACC 2011
Intermediate Aggressive Conservative
PRAMI CuLPRIT Compare-ACUTE
Better than … Better than …
DANAMI-3
SLIDE 6
MVD PCI in STEMI: evidence
PRAMI Immediate and Angio-guided COMPARE-ACUTE Immediate and FFR-guided CULPRIT Immediate or staged and Angio-guided DANAMI 3 Staged and FFR-guided
Complete Revascularisation better than « culprit-only »
Complete revascularisation in STEMI with MVD Question is no longer YES or NO ? But When to do non IRA PCI ? How to assess non IRA ?
SLIDE 7
STEMI + MVD: studies
Studies assessed ‘systematic’ approach Limit of EBM “one size fits all” Larger studies ongoing (COMPLETE)
SLIDE 8
Each ‘STEMI with MVD’ is different !
Different patient Different anatomy →Individualized strategy !
« rule and exceptions »
SLIDE 9
STEMI with MVD: strategy
Staged PCI Immediate Conservative
Default strategy
SLIDE 10
STEMI with MVD: strategy
Straighforward pPCI « Simple » Non-culprit Unclear culprit Difficult access
Default strategy
Staged PCI Immediate Conservative
HD instability Refractory angina Abnormal Flow
SLIDE 11
Immediate Approach
46-year-old patient with lateral STEMI Haemodynamically stable Straightforward primary PCI Critical and focal ‘non culprit’
SLIDE 12
STEMI with MVD: strategy
Elderly Patient Co-morbidities Very complex lesion (CTO, Ca)
Default strategy
Staged PCI Immediate Conservative
SLIDE 13
Conservative Approach
91-year-old patient with inferolateral STEMI Complex primary PCI (3 stents, contraste), diffuse disease LAD
SLIDE 14
STEMI with MVD: strategy
Staged PCI Immediate Conservative Questions
Timing of « staged »
SLIDE 15
Timing of staged
In Hospital Urgent < 24-48h New Hospitalisation « Hours » « Days » « Weeks »
Default strategy
SLIDE 16
Timing of staged
« Hours » « Days » « Weeks »
Default strategy
HD instability Refractory angina Arythmia
In Hospital Urgent < 24-48h New Hospitalisation
SLIDE 17
Timing of staged
« Hours » « Days » « Weeks »
Default strategy
Non-critical lesions Financial Constraint
In Hospital Urgent < 24-48h New Hospitalisation
SLIDE 18
STEMI with MVD: strategy
Staged PCI Immediate Conservative Questions
Timing of « staged »
How to assess Non-culprit ?
SLIDE 19 STEMI patients with successful culprit lesion PCI (primary, rescue or pharmaco-invasive) and ≥ 50% stenosis in at least one additional non-culprit lesion Randomization 1:1 Complete revascularisation Angio-guided PCI
(during the index hospital admission†)
+ OMT Complete revascularisation FFR-guided PCI
(during the index hospital admission †)
+ OMT Follow-up : Discharge, 1, 6 and 12 months Primary Efficacy Outcome: death or non-fatal MI or unplanned hospitalization leading to urgent revascularization at 12 months
FLOWER-MI
1170 patients 40 centres 2,5 ans
PI: Etienne PUYMIRAT
SLIDE 20
FFR in Non-culprit lesions: Flower-MI
Woman 78 Year-old, Anterior STEMI, Randomized FFR Days 3 FFR=0.88 !
SLIDE 21
STEMI with MVD: strategy
Staged PCI Immediate Conservative
Questions
Timing of « staged »
How to assess Non-culprit ? Specific Situations Cardiogenic shock
SLIDE 22 STEMI with MVD and shock
End of the Dogma of Complete Revascularisation cardiogenic shock ?
« Culprit-only » better than complete Revascularisation
Thiele et al, NEJM 2017
CULPRIT-SHOCK Study
SLIDE 23
STEMI with MVD: strategy
Staged PCI Immediate Conservative
Questions
Timing of « staged »
How to assess Non-culprit ? Specific Situations Cardiogenic shock LM as non-culprit
SLIDE 24
LM as non-culprit in STEMI
« Flow only » technique and Heart Team ? Immediate non-culprit because on same vessel ? Usual Management of STEMI MVD ?
SLIDE 25
LM as non-culprit in STEMI
Primary PCI LCx - PCI Distal LM day 3 - IVUS-guided - POT-Side-POT
SLIDE 26
Management of MVD in STEMI
Intermediate « staged » in-hospital as default strategy Individualized for each patient 1) Strategy
Aggressive or Conservative in selected cases
2) Timing if staged
Based on primary PCI / Patient / Anatomy 3) Remaining Quesitons ? FFR > Angiography for non-culprit in STEMI
SLIDE 27
Thank you …
SLIDE 28
Management of MVD in STEMI
Intermediate « staged » in-hospital as default strategy Individualized for each patient 1) Strategy
Aggressive or Conservative in selected cases
2) Timing if staged
Based on primary PCI / Patient / Anatomy 3) Remaining Quesitons ? FFR > Angiography for non-culprit in STEMI
SLIDE 29
SLIDE 30 PRAMI Study
Wald et al, NEJM 2013
Aggressive Conservative
vs
STEMI patients with MVD (n=465) Non IRA Revascularisation Immediate (100%) Angio-guided PCI
SLIDE 31 CULPRIT study
STEMI patients with MVD (n=296) Non IRA Revascularisation Immediate (64%)
- r staged within index admission (36%)
Angio-guided PCI
Gershlick et al, JACC 2015
Benefit of MVD revascularisation
Aggressive Conservative
vs
SLIDE 32 Smits et al, NEJM 2017
COMPARE ACUTE
Benefit of MVD revascularisation
STEMI patients with MVD Immediate (83%)
- r staged within index admission (36%)
FFR-guided PCI
Aggressive Conservative
vs
SLIDE 33 DANAMI-3 study
Engstrom et al, Lancet 2015
Benefit of MVD revascularisation
STEMI patients with MVD (n=627) Non IRA Revascularisation Staged within index admission FFR-guided PCI
Conservative
vs
Intermediate
