**5.3. Clinical case: using a calculator for a personalized selection of the optimal revascularization strategy in a patient with STEMI and MVCAD**

Female, 64 years old, was admitted to the hospital with STEMI. The time from onset of symp‐ toms to hospital admission was 4 h. The patient had a number of cardiovascular risk factors: diabetes, hypertension, PA (two‐sided stenosis of internal carotid arteries), and residual effects of stroke. ECG showed signs of ST‐segment elevation in leads V1–V5 > 2 mm. Ejection fraction on echocardiography was 33%.


**Table 11.** Patient clinical and demographic features.


**Table 12.** Baseline angiographic characteristics.



**Table 13.** Characteristics of vascular access and implanted stents in patient groups.

According to angiography data, multiple coronary disease occurred: subtotal lesion of the prox‐ imal and distal segment of right coronary artery (RCA), thrombotic occlusion of the proximal segment of left anterior descending (LAD) artery with blood flow TIMI 0, subtotal bifurcation stenosis of circumflex (Cx) artery (**Figure 3**).


**Table 14.** Outcomes after 1 year of follow‐up.

female gender showed significant predictive ability of an adverse outcome for patients treated with MPS, while past medical history of MI or stroke, PA, arterial hypertension, three‐vessel dis‐ ease, and the use of non‐DES were the predictors of an adverse outcome in those treated using MSS approach. The following clinical case represents an example of utilizing interactive calculator for the selection of the optimal revascularization strategy in a patient with STEMI and MVCAD.

Female, 64 years old, was admitted to the hospital with STEMI. The time from onset of symp‐ toms to hospital admission was 4 h. The patient had a number of cardiovascular risk factors: diabetes, hypertension, PA (two‐sided stenosis of internal carotid arteries), and residual effects of stroke. ECG showed signs of ST‐segment elevation in leads V1–V5 > 2 mm. Ejection

**n % n %**

**5.3. Clinical case: using a calculator for a personalized selection of the optimal** 

**Variables MPS (n = 91) MSS (n = 236) Р**

Age, years 59.2 ± 10.2 60.1 ± 10.2 0.6 Male gender 62 68.1 154 65.3 0.6 LVEF, % 51.1 ± 8.8 50.7 ± 7.8 0.97 Arterial hypertension 79 86.8 208 88.1 0.9 Diabetes mellitus 17 18.7 49 20.8 0.8 Peripheral artery disease 20 21.9 68 28.8 0.4 Past medical history of MI 9 9.9 40 16.9 0.3 Past medical history of stroke 0 12 5.1 0.5 Acute heart failure (Killip class II) 11 12.1 28 11.9 0.8

**Variables MPS (n = 91) MSS (n = 236) Р n % n %**

SYNTAX score 18.9 ± 7.5 21.5 ± 8.6 0.1 LAD‐IRA 36 39.5 86 36.4 0.8 Cx‐IRA 17 18.7 53 22.5 0.8 RCA‐IRA 38 41.7 97 41.1 0.9

50 54.9 132 55.9 0.9

IRA—infarct‐related artery; LAD—left anterior descending artery; Cx—circumflex artery; RCA—right coronary artery.

**revascularization strategy in a patient with STEMI and MVCAD**

fraction on echocardiography was 33%.

32 Interventional Cardiology

LVEF—left ventricular ejection fraction; MI—myocardial infarction.

**Table 11.** Patient clinical and demographic features.

**Table 12.** Baseline angiographic characteristics.

Three‐vessel disease


**Table 15.** Prognostic factors of unfavorable outcome depending on the revascularization strategy.

Using our original calculator, we counted the probability of an adverse outcome for MPS and MSS strategies (**Figure 4**). As seen from **Figure 4**, MPS strategy was selected as favorable, while MSS strategy showed a poor prognosis for the patient.

Hence, the patient underwent multivessel stenting of LAD, Cx and RCA (five DES implanted in total) (**Figure 5**).

The patient's conditions were satisfactory. On the 14th day, the patient was discharged from the hospital. There was no angina but patient experienced chronic heart failure II‐III functional Current Concept of Revascularization in STEMI Patients with Multivessel Coronary Artery Disease... http://dx.doi.org/10.5772/67884 35

**Figure 3.** Angiography of the patient with STEMI and multiple coronary disease. A: Subtotal lesion of the proximal and distal segment of right coronary artery; B: Thrombotic occlusion of the proximal segment of left anterior descending artery and subtotal bifurcation stenosis of circumflex artery.

class (NYHA classification). Current diabetes and arterial hypertension were adequately controlled with proper medications. After 2 years, the patient underwent repeated coronary angiography. There were no stenoses of coronary arteries (**Figure 6**). According to echocar‐ diography, LVEF was 45%, with a remained anterior wall hypokinesis.

Therefore, we successfully selected an optimal revascularization strategy. This restored the function of anterior myocardial wall, prevented destabilization of Cx and RCA stenosis, and provided a satisfactory quality of life.

#### **5.4. Conclusions**

Using our original calculator, we counted the probability of an adverse outcome for MPS and MSS strategies (**Figure 4**). As seen from **Figure 4**, MPS strategy was selected as favorable,

Hence, the patient underwent multivessel stenting of LAD, Cx and RCA (five DES implanted

The patient's conditions were satisfactory. On the 14th day, the patient was discharged from the hospital. There was no angina but patient experienced chronic heart failure II‐III functional

while MSS strategy showed a poor prognosis for the patient.

**Risk factor Presence of risk factor Prognostic coefficients for** 

Elderly age No 0.031 0.132

Female No 0.048 0.169

Peripheral atherosclerosis No 0.071 0.132

Past medical history of MI No 0.049 0.1353

Arterial hypertension No 0.125 0.043

Diabetes mellitus No 0.068 0.15

Three‐vessel disease No 0.064 0.097

SYNTAX score ≥23 No 0.045 0.150

LVEF (3) ≤40% 0.111 0.077

DES No 0.075 0.182

MI—myocardial infarction; LVEF—left ventricular ejection fraction; DES—drug‐eluting stents.

**Table 15.** Prognostic factors of unfavorable outcome depending on the revascularization strategy.

**MPS**

Yes 0.192 0.195

Yes 0.138 0.134

1 0.079 0.144 2 0.091 0.214

Yes 0.1 0.203

Yes 0.3 0.25

Yes 0.072 0.165

Yes 0.111 0.163

No – 0.147 Yes – 0.273

Yes 0.091 0.189

Yes 0.16 0.156

(2) 41–49% 0.148 0.224 (1) ≥50% 0.036 0.128

Yes 0.078 0.041

**Prognostic coefficients for** 

**MSS**

in total) (**Figure 5**).

Acute heart failure (Killip

34 Interventional Cardiology

Past medical history of

stroke

class)

Here we defined the risk factors of an adverse outcome and designed a calculator for the personalized choice of the optimal revascularization strategy for patients with STEMI and MVCAD.

**Figure 4.** Using the model to calculate the probability of unfavorable prognosis for MPS (A) and MSS strategies (B); 1—presence of factor; 0—absence of factor; 3—LVEF ≤ 40%; PA—peripheral atherosclerosis; MI—myocardial infarction; AH—arterial hypertension; EF—ejection fraction; DES—drug‐eluting stents.

**Figure 5.** Angiography of the patient with STEMI after stenting. A—LAD and Cx; B—RCA.

**Figure 6.** Angiography of the patient with STEMI 24 months after stenting A—RCA; B—LAD and Cx.
