Dr. O'Neill discussed whether patients with acute coronary syndromes should be partially or completely revascularized following initial therapy. Patients with acute coronary syndromes, such as myocardial infarction, present with one or more vessels occluded.

Patients who presented with single lesions were usually treated with angioplasty. 40% of patients with complex lesions were treated with cardiac bypass surgery. Patients with multiple lesions had a significantly higher recurrent event rate. This was seen as a larger number of repeat angioplasties, recurrent ischemia and cardiac bypass surgeries.

Ejection fraction is a more important determinant of mortality than complete or incomplete revascularization. Patients with preserved ventricular function do well long-term whether they are completely or incompletely revascularized. Patients with ejection fractions less than 40% who are completely revascularized have less mortality 2 years after treatment. Dr. O'Neill concluded patients with poor ventricular function should be completely revascularized. Complete revascularization also results in a lower recurrence of angina.

Dr. O'Neill hypothesized that coronary lesions are part of a systemic process. To demonstrate a systemic response, Dr. O'Neill's laboratory measured serum levels of C-reactive protein and leukocytes in patients with single and multiple complex lesions. C-reactive protein indicates the occurrence of a systemic inflammatory process that is not limited to the coronary artery. The results indicate patients with multiple lesions had higher levels of C-reactive protein and leukocytes.

Patients with multiple lesions often presented with stenosis in other vessels. Many of these patients received multiple stents in the same vessel. Patients receiving multiple interventions had a lower survival rate one year later. Survival rate was affected by a reduced ejection fraction (less than 40%) and being female. Dr. O'Neill recommended referring these patients for cardiac bypass surgery followed by complete revascularization.

Patients with cardiogenic shock who are treated with angioplasty should be completely revascularized. These patients can be difficult to manage. Intervention with multiple vessel disease and cardiogenic shock results in 67% mortality.

When multiple vessel disease is present, an acute diffuse, systemic inflammatory process is present. Dr. O'Neill notes the need for systemic treatment in addition to the mechanical treatment provided by angioplasty, stents or cardiac bypass surgery. Dr. O'Neill suggests this combined approach may lead to increased survival.