ABC | Volume 115, Nº2, August 2020

Original Article Cadore et al. Preventive Angioplasty in Myocardial Infarction Arq Bras Cardiol. 2020; 115(2):229-237 within 24 hours. Glycoprotein IIb/IIIa inhibitor was used in 23 (27.1%) patients. Regarding the SYNTAX score, 41 (48.2%) patients had a low score, while 44 (51.8%) had a moderate score. No patient had a high SYNTAX score, and there was no statistically significant difference between the two revascularization strategies regarding the distribution of the scores. Clinical Outcomes Overall mortality was 8.2%, and 86% of deaths occurred in hospital. The chance of both the primary and secondary outcomes occurring was significantly greater among individuals treated with IR when compared to those treated with CR (OR 5.1, 95% CI 1.6-16.1 vs. OR 5.2, 95% CI 1.2-22.9, respectively). If the chance of cardiac death is analyzed separately, the result was similar (OR 6.4, 95% CI 1.2-35.3), as described in Table 3. Deaths occurred predominantly in hospital, and only one patient died in the late stage of the IR strategy. In multivariate analysis, as described in Table 4, CR was associated with a decreased chance of both primary and secondary outcomes occurring regardless of sex, age, diabetes, culprit lesion in the LAD, and presence of LAD lesion and ejection fraction < 50%. Also, CR was associated with a decreased chance of the primary outcome occurring regardless of the ventricular wall affected and the extent of CAD. The Kaplan-Meier curves showed a decreased 12-month survival in patients with multivessel disease post-STEMI who underwent IR (p = 0.017) (Figure 1). Discussion In this real-world practice registry, we showed that the CR strategy is associated with a significant reduction in hard outcomes in a 1-year follow-up when compared to the IR strategy. Also, the treatment of nonculprit arteries during primary PCI was uncommon, as most patients with multivessel CAD and STEMI were managed with a staged approach within 40 days of the index event. Multivessel CAD occurs in approximately 40-50% of patients with STEMI 3-4 and is considered a strong independent predictor of mortality. 5 In our study population, the prevalence was about 35%. The natural history of STEMI demonstrates that the occurrence of more generalized pathophysiological derangements has the potential to compromise coronary perfusion beyond the culprit artery distribution and destabilize plaque throughout the coronary vascular bed. 13 The pathological process of STEMI involves the entire coronary tree, and the dynamics of this specific inflammatory process is greater in the first month following the acute event, 14 which may explain an increased mortality rate within 30 days, 15 as seen in the present study. Because these patients have poor prognosis, the role of CR within the context of STEMI should be examined considering the impact of the aforementioned factors on determining whether an aggressive strategy could provide clinical benefit. 13 Consistent with the still conservative recommendations of contemporary guidelines for real-world clinical practice, several registries demonstrate that the use of multivessel approach ranges from 9% to 24.4%. 16-18 In the ProACS (Portuguese Registry of Acute Coronary Syndromes) registry, for example, Table 2 – Coronary intervention and drug therapy (n = 85) Revascularization strategy Overall Complete Incomplete p Previous thrombolytic therapy 3 (3.5%) 3 (5.2%) 0 0.57* Stent type 0.30* Bare-metal 76 (89.4%) 50 (86.2%) 26 (96.3%) Drug-eluting 9 (10.6%) 8 (13.8%) 1 (3.7%) Glycoprotein IIb/IIIa inhibitors 23 (27.1%) 14 (24.1%) 9 (33.3%) 0.53 Medical therapy within 24 h ASA 85 (100%) 58 (100%) 27 (100%) - Clopidogrel 85 (100%) 58 (100%) 27 (100%) - Statin 85 (100%) 58 (100%) 27 (100%) - Beta-blocker 43 (50.6%) 26 (44.8%) 17 (63.0%) 0.19 ACEI/ARB 40 (47.1%) 27 (46.6%) 13 (48.1%) 0.99 Nitrate 30 (35.3%) 20 (34.5%) 10 (37.0%) 0.99 SYNTAX score 0.34* Low 41 (48.2%) 30 (51.7%) 11 (40.7%) Moderate 44 (51.8%) 28 (48.3%) 16 (59.3%) High — — — Values are absolute and relative frequency. p: probability value; analysis of variance was used for age; for the others, Pearson’s chi-square text or *Fischer’s exact test was used. ASA: acetylsalicylic acid; ACEI: angiotensin-converting enzyme inhibitor; ARB: angiotensin receptor blocker. 232