Американский Научный Журнал PATIENTS WITH ISCHEMIC HEART DISEASE AND MULTIVESSEL CORONARY ARTERY DISEASE AFTER SUCCESSFUL STENTING CLINICAL-RELATED ARTERY IN ACUTE CORONARY SYNDROME WITHOUT ST-SEGMENT ELEVATION: A COMPARISON OF METHODS FOR COMPLETE MYOCARDIAL REVASCULARIZATION

Annotation. In patients with ischemic heart disease and multivessel lesions after successful stenting of the clinical-dependent artery using stents of the 3rd generation with drug coating for acute coronary syndrome without ST segment elevation and intermediate severity of lesions on the SYNTAX SCORE, when performing full functional revascularization, there are no differences in the indicators of large cardiovascular events between coronary artery bypass grafting and percutaneous coronary interventions Скачать в формате PDF
4 American Scientific Journal № ( 27 ) / 20 19
МЕДИЦИНА И СТОМАТОЛОГИЯ

PATIENTS WITH ISCHEM IC HEART DISEASE AND MULTIVESSEL CORONAR Y ARTERY
DISEASE AFTER SUCCES SFUL STENTING CLINIC AL -RELATED ARTERY IN ACUTE
CORONARY SYNDROME WI THOUT ST -SEGMENT ELEVATION: A COMPARISON OF
METHODS FOR COMPLETE MYOCARDIAL REVASCUL ARIZATION

Aleksandr V. Bocharov
Candidate of Medicine Sciences,
Kostroma Regional
Clinical Hospital named after Korolev E.I., Kostroma
Leonid V. Popov
Doctor of Medical Science s,
National Medical -Surgical
Center named after N.I. Pirogov, Moscow

Annotation. In patients with ischemic heart disease and multivessel lesions after successful stenting of the
clinical -dependent artery using stents of the 3rd generation with drug coatin g fo r acute coronary syndrome without
ST segment elevation and intermediate severity of lesions on the SYNTAX SCORE, when performing full
functional revascularization, there are no differences in the indicators of large cardiovascular events between
corona ry a rtery bypass grafting and percutaneous coronary interventions.
Keywords: coronary heart disease, coronary artery bypass grafting, percutaneous coronary intervention,
acute coronary syndrome without ST -segment elevation.

Coronary heart disease (CHD) is th e main cause
of death and disability, a significant contribution to
which is made by acute coronary syndrome (ACS) [1].
Most often occurs ACS without ST segment
elevation (nonSTEMI). This is confirmed by a large
number of coronary revascularization in this pathology
[2].
Patients with nonSTEMI and multi -vessel
coronary bed lesion represent a complex task for the
participants of the "heart team" in selecting the best
strategy of complete revascularization of the
myocardium. This is due to the severe conditio n of
patients, a combination of several risk factors and
chronic diseases, the prevalence of atherosclerotic
lesions [3], the lack of specific recommendations for
myocardial revascularization [4].
In everyday clinical prac tice, patients with
nonSTEMI urgen tly performed stenting (PCI) of the
clinical -dependent artery (CDA) and the second stage -
complete endovascular revascularization or coronary
artery bypass grafting (CABG).
The aim of the study was to compare the results of
PCI with the use of 3rd generat ion drug -coated stents
and CABG in patients with previously successfully
performed PCI CDA with the use of 3rd generation
drug -coated stents for nonSTEMI for two years of
follow -up.
Materials and methods. The study include d 140
patients with coronary arter y disease and multivessel
coronary artery disease who underwent emergency
CDA stenting for nonSTEMI, and subsequently -
complete functional revascularization not later than 90
days from the date of the PCI CDA. Complete
functional revascularization was per formed by CABG
(CABG group) or PCI methods using 3 -generation
stents with drug coating and biodegradable polymer
(PCI group).
For PCI were used stents 3 -generation drug -
eluting and sirolimus bioresorbable polymer
"CALYPSO" producer "Angioline", Russia.
The diameter of the implantable stents was
selected based on the distal reference diameter of the
coronary artery, the length - from the need to overlap
the artery section not less than 5 mm distal from the
edge of t he atherosclerotic plaque in both direction s.
Coronary artery PCI was performed according to
the standard procedure, in particular, pre -dilation, stent
implantation and, if necessary, post -dilation using high -
pressure cylinders.
In the presence of a bifurc ation lesion, protection
of the lateral bra nch by a conductor was used. The one -
cent strategy of stenting was preferable, in the presence
of indications - the occurrence of pain syndrome,
slowing blood flow, compromising the mouth of the
lateral branch - "kissing -dilation" was carried out,
while ma intaining complications - stenting of the
lateral branch.
Criteria for success of PCI: blood flow TIMI III,
residual stenosis no more than 10%, disappearance of
objective and subjective symptoms of acute myocardi al
ischemia after intervention; and was suc cessful in
100% of cases in both groups.
Before performing PCI, patients received a
loading dose of clopidogrel, acetylsalicylic acid,
clopidogrel, beta -blockers, statins and angiotensin -
converting enzyme inhibito rs were also prescribed.
CABG was performed by a single technique – the
imposition of a mammary shunt on the anterior
descending artery and venous shunts on other arteries
in the presence of indications in terms of
cardiopulmonary bypass, normothermia, col d blood
cardioplegia.
The CABG group includ ed 74 patients - complete
myocardial revascularization was performed by
CABG.

American Scientific Journal № (27 ) / 201 9 5
66 patients were in the group of PCI,
revascularization of the coronary bed in this group was
carried out by the method of PCI.
Exclusi on criteria: age less than 18 and more than
80 years prior to PCI or CABG, lack of adherence to
drug therapy, contraindications to the reception of
disaggregants, the presence of severe comorbidities
that limit the survival of patients, the inability to
perform full functional revascularization, th e severity
of coronary lesions on the scale of Syntax less than 22
points and more than 33 points, the left coronary artery
trunk.
The long -term results were evaluated quarterly
over two years. End points of obser vation -
cardiovascular mortality, myocardi al infarction, acute
cerebrovascular accident, re -revascularization and
MACCE.
Statistical processing was performed using the
program Statistica version 13.3 (TIBCO SoftwareInc.,
2017, http://statistica.io). The r esults are presented as
mean and standard d eviation (M±SD) at normal
distribution, median with interquartile range of 25%
and 75% percentiles at asymmetric distribution. The
type of distribution of quantitative variables was
evaluated by the Kolmogorov – Smirnov criterion with
Lillifors correction. When comparing quantitative data,
the Mann – Whitney U – test with continuity correction
was used. Two -sided Fisher criterion was used to
compare qualitative variables. The ratio of the chances
of the development of large vascular events and the
return of the angina clinic was calculated by four -field
tables. Statistically significant differences between the
groups were considered at p <0.05.
Results. There were no statistically significant
differences in clinical , demographic and operational
characteristi cs between the groups (tab. 1, table. 2),
except for the number of Smoking patients, which was
higher in the PCI group.

TABLE 1.
CLINICAL CHARACTERIS TICS OF PATIENTS

TABLE 2.
ANGIOGRAPHIC AND OPE RATIONAL CHARACTERIS TICS OF PATIENTS

Indicator

Group CABG
(n = 74)
Group PCI
(n = 66) p
Age, years 59,7 5,5 60,2 7,3 0,85
Female sex, n (%) 14 (18,9%) 11 (16,7%) 0,82
Body mass index 28,2 4,5 28,7 5 0,64
Generalized atherosclerosis, n (%) 40 (54,1%) 58 (87,9%) 0,1
Hyperlipidemia, n (%) 72 (97,3%) 66 (100%) 1,0
Arterial hypertension, n (%) 72 (97,3%) 66 (100%) 1,0
Diabete s mellitus, n (%) 13 (17,6%) 11 (16,7%) 0,16
Smoking, n (%) 21 (28,4%) 27 (41,0%) 0,03
A history of myocardial infarction, n (%) 24 (32,4%) 11 (16,7%) 0,52
Acute cerebrovascular accident in history, n (%) 4 (5,4%) 6 (9,1%) 1,0
Angina of the III -IV func tional class according to the
classification of the Canadian Heart Society, n (%) 73 (98,6%) 66 (100%) 0,85
Heart failure III -IV functional class according to NYHA
classification, n (%) 22 (29,7%) 18 (27,3%) 0,36
Left ventricular ejection fraction after stenting of a clinically
dependent artery,% 57,9 6,2 57,1 7,6 0,36
Euroscore II, points 1,4 0,6 1,6 2,6 0,12
Time to complete revascularization, day 68,2 19,2 74,5 15,4 0,06
Indicator Gr oup CABG
(n = 74)
Group PCI
(n = 66) p
Localization of clinically dependent artery, n (%)
Anterior descending artery
Circumflex artery
Right coronary artery

24
29
21

33
12
21

0,04
0,009
0,71
The severity of the lesion of the coronary bed on the SYNTAX
scale, points 26,4 3,8 26,3 2,5 0,68
The average number of implanted stents in a clinically -
dependent artery, n (%) 1,1 0,35 1,2 0,45 0,66
The average length of the stented area in the clinically
dependent artery, mm 24,2 7,9 27,3 13,2 0,28
The average diameter of stents implanted into clinic -dependent
artery, mm 3,1 0,6 3,1 0,3 0,64

6 American Scientific Journal № ( 27 ) / 20 19
Analysis of the results (table. 3) showed the
difference between the groups in the frequency of re -
revascularization and MACCE, which were higher in
the PCI group.
TABL E 3.
RESEARCH RESULT
Discussion. The question of choosing t he optimal
tactics of revascularization in patients with nonSTEMI
and multivessel lesions is relevant today. Timely
myocardial revascularization is a leading factor that
improves the survival of the above -mentioned group of
patients. Recommendations of the European society of
cardiology [4] suggest that patients with nonSTEMI
and multi -vascular lesions require mandatory
revascularization of the coronary bed, but the decision
on its type, timing a nd phasing should be taken by the
"heart team".
The lack of cl ear recommendations leads to the
choice of a suboptimal strategy of invasive treatment in
some patients and suboptimal results in the long term.
The choice of PCI CDA as the first stage of
myoca rdial revascularization in high -risk patients with
nonSTEMI an d multivessel lesions is logical [5].
Determination of the optimal tactics of complete
revascularization of the myocardium in the next stage,
causes considerable difficulties. Often, preference is
given to the endovascular method due to the low
invasivenes s of the intervention, the absence of risks of
General anesthesia, and the short period of
hospitalization [6]. The leading criterion for choosing
the method of complete revascularization of the
coronary bed in patients with multi -vascular lesions is
the p revalence and severity of atherosclerotic process
in the coronary arteries, which is estimated on the scale
of Syntax [11]. Taking into account the high values of
the Syntax scale in both groups of our study
(SyntaxScore was 26.4±3.8 and 26.3±2.5 points in the
groups of CABG and PCI, respectively), we can talk
about the need for wider use of CABG as a method of
complete revascularization in patients after successful
PCI CDA, even with the use of modern stents of 3rd
generation with drug coating.
Our results have shown the benefit of CABG in
patients with previously successful PCI CDA about
nonSTEMI and multi -vessel lesions according to the
frequency of repeated revascularization and MACCE.
Conclus ion. Patients with coronary artery disease
and multivessel cor onary lesions, who had successfully
performed stenting of the clinical -dependent artery
using stents of the 3rd generation with drug coating for
acute coronary syndrome without St segment elevat ion,
and intermediate severity of lesions on the SYNTAX
scale when performing full functional revascularization
by coronary artery bypass grafting or stenting methods
have no differences, except for the frequency of
repeated revascularization and MACCE, wh ich were
higher in the stenting group.

References:
1. Chazova I. E., Oschepkova E.V. Fight with
cardiovascular disease: problems and ways to solve
them at the present stage. Bulletin Roszdravnadzor.
2015; 5: 7 – 10
2. Bockeria L.A., Alekyan B.G. Endovascular
diagnosis and treatment of disease of the heart and
blood vessels in Russian Fe deration – 2015. Moscow:
Nauchnyy Tsentr Serdechno -Sosudistoy Khirurgii
imeni A.N. Bakuleva Rossiyskoy Akademii
Meditsinskikh Nauk; 2016
3. Fukui T., Tabata M. Early and long -term
outcomes of coronary artery bypass grafting and
percutaneous coro nary intervent ions in patients with
left main disease: single -center results of
multidisciplinary decision making. Gen Thorac
Cardiovasc Surg. 2014; 62(5): 301 – 307
4. Patrono C., Collet J. -Ph., Mueller Ch. et al.
2015 ESC guidelines for the management of ac ute
coronary s yndromes in patients presenting without
persistent ST -segment elevation. European Heart
Journal. 2015. DOI: 10.1093/eurheartj/ehv320
5. Ranasinghe I., Alprandi -Costa B., Chow V.,
Elliot J.M. et al. Risk stratification in the setting of non -
ST el evation acute coronary syndromes 1999 -2007.
Am J Cardiol. 2011; 108: 617 - 624
6. Ben -Gal Y., Moses J.W., Mehran R., Lansky
A.J. et al. Surgical versus percutaneous
revascularization for multivessel disease in patients
with acute coronary syndromes: analysis from the
ACUIT Y (Acute Catheterization and Urgent
Intervention Triage strategY) trial. JACC Cardiovasc
Interv. 2010; 3: 1059 - 1067
7. Palmerini T., Genereux P., Caixeta A., Cristea
E. et al. Prognostic value of the SYNTAX score in
patients with acute coronar y syndromes un dergoing
percutaneous coronary intervention: analysis from the
ACUITY (Acute Catheterization and Urgent
Intervention Triage strategY) trial. J Am Coll Cardiol.
2011; 57: 2389 - 2397
Indicator Group CABG
(n = 74)
Group PCI
(n = 66) p
Cardiovascular mortality, n (%) 2 0 0,5
Nonfatal myocardial infarction, n (%) 0 4 0,47
Nonfatal acute cerebrovascular accident, n (%) 0 0 1,0
Repeated revascularization, n (%) 0 5 0,02
Return of the clinic of angina pectoris that does not require re -
revascularization (not heavier than Class II according to the
classification of the Canadian Heart Society, n (%)
2 1 1,0
MACCE, n (%) 2 9 0,03