Angiographically Guided Complete Revascularization Versus Selective Stress Echocardiography-Guided Revascularization
Ramón Calviño-Santos1, Rodrigo Estévez-Loureiro2, Jesús Peteiro-Vázquez1,3
1Department of Cardiology, Hospital Universitario A Coruña, INIBIC, Spain (R.C.-S., J.P.-V., J.S.-F., A.B.-M., J.A.R.-F., G.A.-L., P.P.-E., X.F.-R., R.S.-M., T.S.-P., N.V.-G., J.M.V.-R.).
Insights
Stress echocardiography-guided revascularization showed similar outcomes to complete angiographically guided revascularization in ST-elevation myocardial infarction patients with multivessel disease. This approach may reduce unnecessary procedures before hospital discharge.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Complete revascularization in ST-elevation myocardial infarction (STEMI) with multivessel disease may improve outcomes compared to infarct-related artery (IRA)-only treatment.
- Selecting non-IRA lesions for revascularization requires specific methods.
- This study compares clinical outcomes of two guidance methods for non-IRA lesion revascularization in STEMI patients.
Purpose of the Study:
- To compare the clinical outcomes of complete angiographically guided revascularization versus stress echocardiography-guided revascularization in STEMI patients with multivessel disease.
- To assess if stress echocardiography can effectively guide selective revascularization of non-IRA lesions.
- To determine if a guided approach reduces the need for elective revascularization procedures.
Main Methods:
- A randomized clinical trial involving STEMI patients with multivessel disease after successful IRA percutaneous coronary intervention.
- Patients were randomized to either complete angiographically guided revascularization (n=154) or stress echocardiography-guided revascularization (n=152) of non-IRA lesions.
- The primary endpoint was a composite of cardiovascular mortality, nonfatal reinfarction, coronary revascularization, and heart failure readmission at 12 months.
Main Results:
- The trial was stopped early, enrolling 77% of the planned participants.
- A significantly higher proportion of patients in the complete revascularization group (99%) underwent non-IRA lesion intervention compared to the stress echocardiography-guided group (29%).
- The primary endpoint occurred in 14% of patients in both groups (HR 0.95; 95% CI 0.52-1.72; P=0.85), indicating no significant difference.
Conclusions:
- Stress echocardiography-guided revascularization is not significantly different from complete angiographically guided revascularization in STEMI patients with multivessel disease.
- This finding suggests that stress echocardiography guidance can potentially reduce the need for elective revascularization procedures before hospital discharge.
- The study highlights a more selective approach to revascularization guided by functional assessment.
Background:
Recent trials suggest that complete revascularization in patients with acute ST-segment-elevation myocardial infarction and multivessel disease is associated with better outcomes than infarct-related artery (IRA)-only revascularization. There are different methods to select non-IRA lesions for revascularization procedures. We assessed the clinical outcomes of complete angiographically guided revascularization versus stress echocardiography-guided revascularization in patients with ST-segment-elevation myocardial infarction.
Methods:
We performed a randomized clinical trial in patients with multivessel disease who underwent a successful percutaneous coronary intervention of the IRA to test differences in prognosis (composite end point included cardiovascular mortality, nonfatal reinfarction, coronary revascularization, and readmission for heart failure after 12 months of follow-up) between complete angiographically guided revascularization (n=154) or stress echocardiography-guided revascularization (n=152) of the non-IRA lesions in an elective procedure before hospital discharge.
Results:
The trial was prematurely stopped after the inclusion of 77% of the planned study population. As many as 152 (99%) patients in the complete revascularization group and 44 (29%) patients in the selective revascularization group required a percutaneous coronary intervention procedure of a non-IRA lesion before discharge. The primary end point occurred in 21 (14%) patients of the stress echocardiography-guided revascularization group and 22 (14%) patients of the complete angiographically guided revascularization group (hazard ratio, 0.95; 95% CI, 0.52-1.72; P=0.85).
Conclusions:
In patients with ST-segment-elevation myocardial infarction and multivessel disease, stress echocardiography-guided revascularization may not be significantly different to complete angiographically guided revascularization, thereby reducing the need for elective revascularization before hospital discharge.
Clinical Trial Registration:
URL: https://www.clinicaltrials.gov. Unique identifier: NCT01179126.
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