X I have the following potential conflicts of interest to report: x - PowerPoint PPT Presentation

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

STEMI et Patient Pluritronculaire Thomas Cuisset , CHU TIMONE, Marseille, FR High Tech, Janvier 2018

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 ’

Options for MVD management in STEMI

Data before recent studies Meta-analysis Intermediate Better than … Aggressive DANAMI-3 PRAMI CuLPRIT Better than … Compare-ACUTE Conservative Vlaar et al, JACC 2011

MVD PCI in STEMI: evidence Complete Revascularisation better than « culprit-only » 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 in STEMI with MVD Question is no longer YES or NO ? But When to do non IRA PCI ? How to assess non IRA ?

STEMI + MVD: studies Studies assessed ‘ systematic ’ approach Limit of EBM “one size fits all” Larger studies ongoing (COMPLETE)

Each ‘STEMI with MVD’ is different ! Different patient Different anatomy → Individualized strategy ! « rule and exceptions »

STEMI with MVD: strategy Immediate Default strategy Staged PCI Conservative

STEMI with MVD: strategy HD instability Straighforward pPCI Immediate Refractory angina « Simple » Non-culprit Abnormal Flow Unclear culprit Difficult access Default strategy Staged PCI Conservative

Immediate Approach 46-year-old patient with lateral STEMI Haemodynamically stable Straightforward primary PCI Critical and focal ‘non culprit’

STEMI with MVD: strategy Immediate Default strategy Staged PCI Elderly Patient Conservative Co-morbidities Very complex lesion (CTO, Ca)

Conservative Approach 91-year-old patient with inferolateral STEMI Complex primary PCI (3 stents, contraste), diffuse disease LAD

STEMI with MVD: strategy Immediate Timing of « staged » Staged PCI Questions Conservative

Timing of staged Urgent < 24-48h « Hours » Default strategy In Hospital « Days » « Weeks » New Hospitalisation

Timing of staged HD instability Urgent < 24-48h « Hours » Refractory angina Arythmia Default strategy In Hospital « Days » « Weeks » New Hospitalisation

Timing of staged Urgent < 24-48h « Hours » Default strategy In Hospital « Days » Non-critical lesions « Weeks » New Hospitalisation Financial Constraint

STEMI with MVD: strategy Immediate Timing of « staged » How to assess Non-culprit ? Staged PCI Questions Conservative

PI: Etienne PUYMIRAT FLOWER-MI STEMI patients with successful culprit lesion PCI (primary, rescue or pharmaco-invasive) and ≥ 50% stenosis in at least one additional non -culprit lesion 1170 patients 40 centres Randomization 2,5 ans 1:1 Complete revascularisation Complete revascularisation Angio-guided PCI FFR-guided PCI ( during the index hospital admission† ) (during the index hospital admission †) + + OMT 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

FFR in Non-culprit lesions: Flower-MI FFR=0.88 ! Woman 78 Year-old, Anterior STEMI, Randomized FFR Days 3

STEMI with MVD: strategy Immediate Timing of « staged » How to assess Non-culprit ? Staged PCI Questions Specific Situations Cardiogenic shock Conservative

STEMI with MVD and shock End of the Dogma of Complete Revascularisation cardiogenic shock ? « Culprit-only » better than complete Revascularisation CULPRIT-SHOCK Study Thiele et al, NEJM 2017

STEMI with MVD: strategy Immediate Timing of « staged » How to assess Non-culprit ? Staged PCI Questions Specific Situations Cardiogenic shock Conservative LM as non-culprit

LM as non-culprit in STEMI « Flow only » technique and Heart Team ? Immediate non-culprit because on same vessel ? Usual Management of STEMI MVD ?

LM as non-culprit in STEMI Primary PCI LCx - PCI Distal LM day 3 - IVUS-guided - POT-Side-POT

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

Thank you …

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

PRAMI Study STEMI patients with MVD (n=465) Non IRA Revascularisation Immediate (100%) Angio-guided PCI Aggressive Conservative Wald et al, NEJM 2013 vs

CULPRIT study STEMI patients with MVD (n=296) Non IRA Revascularisation Immediate (64%) or staged within index admission (36%) Angio-guided PCI Benefit of MVD revascularisation Aggressive Conservative Gershlick et al, JACC 2015 vs

COMPARE ACUTE STEMI patients with MVD Immediate (83%) or staged within index admission (36%) FFR-guided PCI Benefit of MVD revascularisation Smits et al, NEJM 2017 Aggressive Conservative vs

DANAMI-3 study STEMI patients with MVD (n=627) Non IRA Revascularisation Staged within index admission FFR-guided PCI Benefit of MVD revascularisation Intermediate Conservative Engstrom et al, Lancet 2015 vs