From the Guidelines
The best treatment plan for a 41-year-old male with inferior ST-Elevation Myocardial Infarction (STEMI) who underwent emergency Primary Percutaneous Coronary Intervention (PCI) to the Right Coronary Artery (RCA) with 1 Drug-Eluting Stent (DES), and has severe residual double vessel disease with a low SYNTAX score is to consider Coronary Artery Bypass Graft (CABG) as a potential next step, given the presence of multivessel disease.
Key Considerations
- The patient has already undergone PCI to the RCA, but still has severe residual double vessel disease, indicating the need for further revascularization.
- The low SYNTAX score suggests that the patient's coronary anatomy is not highly complex, which may favor a CABG approach over additional PCI.
- The Heart Team approach is recommended to determine the optimal revascularization strategy, taking into account anatomic complexity, medication compliance, and patient preference 1.
Treatment Options
- CABG: Considered a reasonable option for patients with multivessel disease, especially those with a low SYNTAX score and severe residual disease.
- PCI: May be considered for patients with less complex anatomy and fewer comorbidities, but the presence of severe residual double vessel disease may make CABG a more attractive option.
Guideline Recommendations
- The 2021 ACC/AHA/SCAI guideline recommends a Heart Team approach to determine the optimal revascularization strategy for patients with multivessel disease 1.
- The 2011 ACCF/AHA guideline recommends CABG as a Class I indication for patients with multivessel disease and a low SYNTAX score 1.
From the Research
Treatment Plan for STEMI with Severe Residual Double Vessel Disease
The patient in question has undergone emergency Primary Percutaneous Coronary Intervention (PCI) to the Right Coronary Artery (RCA) with 1 Drug-Eluting Stent (DES) for inferior ST-Elevation Myocardial Infarction (STEMI) and has severe residual double vessel disease with a low SYNTAX score.
Considerations for Revascularization Strategy
- The SYNTAX score has been shown to have prognostic value in assessing outcomes of primary PCIs in STEMI patients with multivessel disease 2.
- A low SYNTAX score indicates less complex coronary artery disease, which may influence the choice of revascularization strategy.
- Studies have demonstrated that incomplete revascularization is associated with higher rates of adverse outcomes, including death, myocardial infarction, and target vessel revascularization 2, 3.
- The residual SYNTAX score (rSS) has been shown to be an independent predictor of Major Adverse Cardiac and Cerebrovascular Events (MACCE) and all-cause mortality during follow-up 3, 4, 5.
Recommendations for Treatment
- Given the patient's low SYNTAX score and severe residual double vessel disease, a staged revascularization strategy may be considered to achieve complete or reasonable incomplete revascularization 4.
- The goal of revascularization should be to achieve an rSS of ≤8, as this has been associated with improved clinical outcomes and reduced risk of adverse events 4, 5.
- The decision to perform additional revascularization procedures should be based on individual patient characteristics, including clinical status, lesion complexity, and operator discretion 5.
Predictive Value of Residual SYNTAX Score
- The rSS has been shown to be a useful tool in predicting clinical outcomes after primary PCI for STEMI, including recurrent MACCE and all-cause mortality 3, 5.
- An rSS of >8 has been identified as a threshold for increased risk of adverse events, with a sensitivity of 70.1% and specificity of 75.3% for predicting 1-year MACCE 5.