Complete versus culprit-only revascularization in ST-elevation myocardial infarction and multivessel disease
Giuseppe Di Pasquale1, Elisa Filippini2, Pier Camillo Pavesi2
1Division of Cardiology, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy. giuseppe.dipasquale@ausl.bologna.it.
Insights
Complete revascularization in ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease shows conflicting evidence. The ongoing COMPLETE trial aims to clarify optimal strategies for non-infarct-related artery interventions.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Multivessel disease in ST-segment elevation myocardial infarction (STEMI) patients is common (30-60%) and linked to higher major adverse cardiac events (MACE).
- Current guidelines generally advise against revascularizing non-infarct-related arteries (non-IRA) unless specific complications arise.
- Conflicting results exist from prior studies on the benefits of complete revascularization versus culprit-lesion-only percutaneous coronary intervention (PCI) in STEMI.
Purpose of the Study:
- To evaluate the optimal revascularization strategy in STEMI patients with multivessel disease.
- To address the uncertainty surrounding complete revascularization versus culprit-only PCI.
- To inform clinical practice pending results from larger trials like COMPLETE.
Main Methods:
- Review of recent randomized studies (PRAMI, CvLPRIT, DANAMI 3-PRIMULTI) and meta-analyses.
- Analysis of conflicting findings between complete revascularization and culprit-only PCI.
- Highlighting the need for robust evidence from large-scale trials.
Main Results:
- Some recent RCTs suggest potential benefits of complete revascularization in STEMI patients with obstructive non-culprit lesions.
- Other trials, like PRAGUE-13, found no significant difference in MACE between strategies.
- Existing meta-analyses show varied results depending on the included study populations (RCTs vs. non-RCTs).
Conclusions:
- Current evidence from randomized trials (totaling ~2000 patients) is insufficient to strongly recommend complete revascularization in STEMI.
- The ongoing COMPLETE trial (3900 patients) is crucial for definitive outcomes on death and myocardial infarction.
- Individualized patient care and timing of non-IRA PCI are recommended until COMPLETE trial results are available.
Abstract:
In 30-60 % of patients presenting with ST-segment elevation myocardial infarction (STEMI), significant stenoses are present in one or more non-infarct-related arteries (IRA). This correlates with an increased risk of major adverse cardiac events (MACE). Current guidelines, do not recommend revascularization of non-culprit lesions unless complicated by cardiogenic shock or persistent ischemia after primary percutaneous coronary intervention (PCI). Prior observational and small randomized controlled trials (RCTs) have demonstrated conflicting results regarding the optimal revascularization strategy in STEMI patients with multivessel disease. Recently, randomized studies (PRAMI, CvLPRIT, and DANAMI 3-PRIMULTI) provide encouraging data that suggest potential benefit with complete revascularization in STEMI patients with obstructive non-culprit lesions. Differently, in the PRAGUE-13 trial there were no differences in MACE between complete revascularization and culprit-only PCI. Several meta-analyses were recently published including randomized and non-randomized clinical trials, showing different results depending on the included trials. In conclusion, the current available evidence from the randomized clinical trials, with a total sample size of only 2000 patients, is not robust enough to firmly recommend complete revascularization in STEMI patients. This uncertainty lends support to the continuation of the COMPLETE trial. This ongoing trial is anticipated to enroll 3900 patients with STEMI from across the world, and will be powered for the hard outcomes of death and myocardial infarction. Until the results of the COMPLETE trial are reported, physicians need to individualize care regarding the opportunity and the timing of the non-IRA PCI.
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