ABC | Volume 115, Nº2, August 2020

Original Article Cadore et al. Preventive Angioplasty in Myocardial Infarction Arq Bras Cardiol. 2020; 115(2):229-237 Based on those findings, the American College of Cardiology (ACC) and the American Heart Association (AHA) updated their guidelines in 2015 with recommendations for both CR and staged approach at the time of primary PCI in hemodynamically stable patients. 4 The 2017 European Society of Cardiology (ESC) guideline followed the same path. 11 The 2015 Brazilian Society of Cardiology (SBC) guideline, in turn, finds it reasonable to treat less complex, severe stenosis located in the coronary system linked to the infarct-related vessel. 12 Conversely, the guideline highlights that these patients are more likely to experience new coronary events within 1 year, thus suggesting that severe coronary stenoses that are not directly related to the index procedure should be managed later with a staged approach. 12 In this study, we aimed to assess real-life outcomes of CR versus treatment of the culprit artery only in patients with STEMI and multivessel disease managed at two hospitals in southern Brazil. Method Study Design A registry study was conducted to evaluate patients with STEMI and multivessel CAD admitted to two medical centers in southern Brazil. Prospective data were collected from October 2015 to March 2016 using hospital admission information. Also, retrospective data were collected from January to September 2015 by reviewing medical records. Primary and secondary outcomes were prospectively assessed by monthly telephone contact for 12 months following hospital discharge for the index event. Patient Selection Male and female patients were included if they were aged ≥ 18 years, were admitted to the study centers in the 6-month period, had diagnosis of STEMI treated with primary PCI, and presented with multivessel CAD on coronary angiography – defined as the presence of a lesion ≥ 70% by visual assessment of the angiogram in at least two projections in more than one coronary artery. Patients who were referred to the hospitals for rescue angioplasty after thrombolytic therapy and had multivessel CAD were also eligible. Patients were excluded if they had undergone previous coronary artery bypass grafting (CABG), had cardiogenic shock at admission, indication for CABG following primary angioplasty, left main coronary artery disease, lesion in the proximal portion of the left anterior descending artery (LAD) or the circumflex artery, or chronic total occlusion of a nonculprit artery (cases which would benefit from CABG at the discretion of the health care team). Data Collection Study data were collected using a standardized form for the period of hospitalization for treatment of the acute event, including demographic characteristics, tests performed in the emergency department, coronary angiography results, administered treatment, as well as follow-up data for a 1-year period. All procedures related to patient care were the responsibility of the health care team, with no influence from the researchers. The study was conducted in accordance with Brazilian resolution no. 466/2012 and was approved by the Research Ethics Committees at both institutions. The prospectively enrolled patients signed an informed consent form after the initial test (coronary angiography); for retrospective data collection, the researchers signed a data confidentiality agreement. Follow-up and Outcomes of Interest Progression and occurrence of in-hospital outcomes were assessed during hospitalization and, subsequently, via telephone contact and review of medical records. The primary outcome was defined as the occurrence of: (1) death from cardiovascular causes; (2) reinfarction, defined as recurrent ischemic pain (although not mandatory), new ST-segment elevation ≥ 0.1 mV or new Q wave in at least two contiguous leads or abnormal (above the upper limit of normal according to the reference range used by the local laboratory or at least 50% above the value in the previous test) levels of serum markers (troponin or creatine kinase-MB); or (3) recurrent angina, defined as persistent pain, need for sublingual nitrate, or readmission due to recurrent angina. The secondary outcome was a composite of: (1) stroke; (2) nonfatal cardiac arrest; (3) major bleeding (defined as the need for blood transfusion due to a drop of more than 3 g/dL in the hemoglobin test, and/or hemoglobin level below 10 g/dL, and/ or hemodynamic instability, and/or prolonged hospitalization due to major bleeding, and/or hemorrhagic stroke; or (4) need for unplanned percutaneous or surgical reintervention. Statistical Analysis Statistical analysis was performed using IBM SPSS Statistics version 22.0 for Windows. Age and time between primary PCI and new procedure were described as mean ± standard deviation. Categorical variables were described as absolute and relative frequency. The distributions of numerical variables were compared between the CR and culprit-artery-only groups using analysis of variance with a single criterion of classification, while those of categorical variables were compared using Pearson’s chi-square test with continuity correction or Fisher’s exact test whenever appropriate. The chance of primary outcome, secondary outcome, and death from all causes occurring were compared between the groups described above using binary logistic regression. In multivariable analysis, models were compared using the likelihood ratio test. Kaplan-Meier curves for STEMI were calculated for CR and IR. Differences in survival rate were assessed by the log-rank test. Odds ratios were described with their respective 95% confidence intervals. Tests with p-value < 0.05 were considered statistically significant. (Seria cardiovascular causes?) Results From January 2015 to March 2016, 248 patients with a diagnosis of STEMI were admitted to the emergency departments at the two study centers; of those, 85 (34.3%) patients had multivessel CAD. 230