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Published on: May 28, 2019
Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous
Anthony H Gershlick1, Jamal Nasir Khan1, Damian J Kelly2
1Department of Cardiovascular Sciences, University of Leicester and National Institute of Health Research Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, United Kingdom.
Insights
Complete revascularization during index admission significantly reduced major adverse cardiac events in ST-segment elevation myocardial infarction patients with multivessel disease. This strategy may be considered, though further trials are needed to confirm survival benefits.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Optimal management for ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease undergoing primary percutaneous coronary intervention (P-PCI) remains unclear.
- Complete revascularization versus infarct-related artery (IRA) only revascularization strategies require comparative evaluation.
Purpose of the Study:
- To compare the efficacy of complete revascularization versus IRA-only revascularization in patients with STEMI and multivessel disease.
- To evaluate the impact of complete revascularization on a composite endpoint of death, recurrent myocardial infarction, heart failure, and ischemia-driven revascularization.
Main Methods:
- The CvLPRIT trial randomized 296 patients with STEMI and multivessel disease to either complete revascularization or IRA-only revascularization.
- Complete revascularization was performed during the index admission (P-PCI or before discharge).
- Randomization was stratified by infarct location and symptom onset time; the primary endpoint was assessed at 12 months.
Main Results:
- The primary composite endpoint occurred in 10.0% of the complete revascularization group versus 21.2% in the IRA-only group (HR 0.45, p=0.009).
- A trend towards benefit was observed early (p=0.055 at 30 days), with nonsignificant reductions in all primary endpoint components.
- No significant differences were found in ischemic burden or safety endpoints (bleeding, nephropathy, stroke).
Conclusions:
- Index admission complete revascularization significantly reduced the composite primary endpoint at 12 months in STEMI patients with multivessel disease.
- Inpatient total revascularization may be considered for these patients.
- Larger clinical trials are necessary to confirm these findings and assess impact on survival.
Background:
The optimal management of patients found to have multivessel disease while undergoing primary percutaneous coronary intervention (P-PCI) for ST-segment elevation myocardial infarction is uncertain.
Objectives:
CvLPRIT (Complete versus Lesion-only Primary PCI trial) is a U.K. open-label randomized study comparing complete revascularization at index admission with treatment of the infarct-related artery (IRA) only.
Methods:
After they provided verbal assent and underwent coronary angiography, 296 patients in 7 U.K. centers were randomized through an interactive voice-response program to either in-hospital complete revascularization (n = 150) or IRA-only revascularization (n = 146). Complete revascularization was performed either at the time of P-PCI or before hospital discharge. Randomization was stratified by infarct location (anterior/nonanterior) and symptom onset (≤ 3 h or >3 h). The primary endpoint was a composite of all-cause death, recurrent myocardial infarction (MI), heart failure, and ischemia-driven revascularization within 12 months.
Results:
Patient groups were well matched for baseline clinical characteristics. The primary endpoint occurred in 10.0% of the complete revascularization group versus 21.2% in the IRA-only revascularization group (hazard ratio: 0.45; 95% confidence interval: 0.24 to 0.84; p = 0.009). A trend toward benefit was seen early after complete revascularization (p = 0.055 at 30 days). Although there was no significant reduction in death or MI, a nonsignificant reduction in all primary endpoint components was seen. There was no reduction in ischemic burden on myocardial perfusion scintigraphy or in the safety endpoints of major bleeding, contrast-induced nephropathy, or stroke between the groups.
Conclusions:
In patients presenting for P-PCI with multivessel disease, index admission complete revascularization significantly lowered the rate of the composite primary endpoint at 12 months compared with treating only the IRA. In such patients, inpatient total revascularization may be considered, but larger clinical trials are required to confirm this result and specifically address whether this strategy is associated with improved survival.
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