ABC | Volume 115, Nº2, August 2020

Original Article Cadore et al. Preventive Angioplasty in Myocardial Infarction Arq Bras Cardiol. 2020; 115(2):229-237 the rate was 19.2%. In our study, the approach was used in 68.2%. According to some authors, discrepancy between current guidelines and clinical practice results from several factors, including lack of clinical evidence and economic issues involving paying sources and current protocols. The subject is controversial and will only be resolved with a broad international study. 19 Within the context of multivessel treatment, our study showed a predominance of patients with double-vessel disease (78.8%), in agreement with studies such as the PRAMI trial, 7 and patients with less complex lesions, as there were no participants with a high SYNTAX score. Those findings suggest that more severe patients – with triple-vessel disease and a high SYNTAX score – had indication for surgical treatment following primary angioplasty at the study centers. With regard to drug therapy, all patients were given dual antiplatelet therapy and statins as recommended in STEMI guidelines. There was no difference in the use of glycoprotein IIb/IIIa inhibitors between the groups (around 27.1%), although a large metanalysis concluded that greater benefits are observed in high-risk patients, such as those undergoing CR. 20 Another highlight is the high rate of bare-metal stenting (89.4%), which differs from the results of randomized clinical trials (RCTs). 7-10 This shows a disparity between patients included in RCTs and real-world patients, which reinforces the importance of population registries. Although RCTs use the most widely accepted design for comparing treatments, they have left many important questions unanswered. Careful review of clinical registry information is believed to provide a complementary approach to RCTs, especially because of the potential inclusion of more representative samples of the target population. Furthermore, as RCTs are conducted at centers of excellence, it remains unclear whether their results can be generalized to usual clinical practice. The operator’s experience, for example, varies across institutions and may interfere with the results. Registries such as the present study show that even in suboptimal conditions the benefit of CR in patients with multivessel disease remains significant. 21 The SCAAR (Swedish Coronary Angiography and Angioplasty Registry) study followed up from 2006 to 2010 a total of 23,342 patients with multivessel disease who underwent coronary angioplasty with IR and assessed its long-term association with death, new intervention, and myocardial infarction. IR at the time of hospital discharge was associated with a high risk of adverse cardiac events within 1 year, with an adjusted hazard ratio of death and the combination of death/ infarction of 1.29 (95% CI 1.12-1.49; p = 0.0005) and 1.42 (95% CI 1.30-1.56; p < 0.0001), respectively. This study was able to demonstrate a significant benefit of CR in reducing mortality, even when a staged approach was used. CR at the index event was uncommon, being performed only in patients with double-vessel disease, favorable anatomy, and lower severity at admission (Killip class I). Another important finding was the significant benefit regarding repeat revascularization and recurrent angina. In patients with STEMI treated with primary PCI at real-world hospital settings, CR does not increase short- and long-term mortality, proving to be safe when a staged approach is used. 22 Table 3 – Clinical outcomes according to revascularization strategy (n = 85) Revascularization strategy Complete n (%) Incomplete n (%) OR (95% CI) p Primary outcome (composite) 6 (10.3%) 10 (37.0%) 5.10 (1.6-16.1) 0.005 Cardiac death 2 (3.4%) 5 (18,5%) Reinfarction — — Angina 4 (6.9%) 5 (18.5%) Secondary outcome (composite) 3 (5.17%) 6 (22.2%) 5.24 (1.2-22.9) 0.022 Stroke — — Nonfatal cardiac arrest 2 (3.4%) — Major bleeding 1 (1.7%) — Reintervention — 6 (22.2%) OR: odds ratio; CI: confidence interval. Table 4 – Independent association between staged revascularization strategy and incidence of primary and secondary outcomes in a 1-year follow-up (n = 85) Primary outcome* OR (95% CI) Secondary outcome † OR (95% CI) Unadjusted 5.1 (1.6-16.1) 5.2 (1.2-22.9) Model 2 ‡ 5.2 (1.6-16.5) 5.1 (1.1-23.0) Model 3 § 5.1 (1.6-16.4) 4.9 (1.1-23.1) Model 4 // 5.1 (1.6-16.4) 5.1 (1.1-24.1) Model 5 ¶ 5.1 (1.6-16.7) 4.3 (0.9-21.0) Model 6 # 4.6 (1.4-15.3) 3.6 (0.7-19.6) Model 7** 4.7 (1.4-15.7) 2.3 (0.4-14.2) OR: odds ratio; CI: confidence interval. *Death, reinfarction, angina; † Stroke, nonfatal cardiac arrest, major bleeding, reintervention. ‡ Adjusted for age and sex. § Model 2 + adjustment for diabetes. // Model 3 + adjustment for culprit lesion in left anterior descending artery (LAD). ¶ Model 4 + LAD lesion and ejection fraction < 50%. # Model 5 + infarction location. **Model 6 + number of lesions. 233