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Postconditioning with Lactate-enriched Blood for Cardioprotection in ST-segment Elevation Myocardial Infarction
Published on: May 28, 2019
Timing of Staged Nonculprit Artery Revascularization in Patients With ST-Segment Elevation Myocardial Infarction:
David A Wood1, John A Cairns1, Jia Wang2
1Centre for Cardiovascular Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada.
Insights
Complete revascularization through staged nonculprit lesion percutaneous coronary intervention (PCI) significantly reduced major cardiovascular events in ST-segment elevation myocardial infarction (STEMI) patients. The benefits of complete PCI were observed consistently, regardless of intervention timing, with long-term outcomes showing the most significant improvements.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- The COMPLETE trial investigated complete versus culprit-only revascularization in ST-segment elevation myocardial infarction (STEMI) patients with multivessel coronary artery disease (CAD).
- Previous findings indicated that staged nonculprit lesion percutaneous coronary intervention (PCI) reduced major cardiovascular (CV) events in this patient population.
Purpose of the Study:
- To evaluate the impact of nonculprit-lesion PCI timing on major CV outcomes.
- To determine the time course of benefits associated with complete revascularization post-STEMI.
Main Methods:
- 4,041 STEMI patients with multivessel CAD underwent either staged nonculprit-lesion PCI or culprit-lesion only PCI after initial culprit-lesion PCI.
- Randomization was stratified by planned timing of nonculprit-lesion PCI: during or after index hospitalization.
- Coprimary outcome was a composite of CV death or myocardial infarction (MI); landmark analyses were conducted at 45 days.
Main Results:
- Complete revascularization reduced CV death or MI when nonculprit-lesion PCI was performed during hospitalization (HR: 0.77; 95% CI: 0.59 to 1.00).
- Similar reductions were observed for PCI performed after discharge (HR: 0.69; 95% CI: 0.49 to 0.97).
- Landmark analysis showed benefit during the first 45 days (HR: 0.86) and a more pronounced benefit after 45 days (HR: 0.69).
Conclusions:
- The benefit of complete revascularization in STEMI patients with multivessel CAD is consistent, irrespective of nonculprit-lesion PCI timing.
- The positive impact of complete revascularization on major clinical outcomes becomes more apparent over the long term.
Background:
The COMPLETE (Complete vs Culprit-only Revascularization to Treat Multi-vessel Disease After Early PCI for STEMI) trial demonstrated that staged nonculprit lesion percutaneous coronary intervention (PCI) reduced major cardiovascular (CV) events in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD).
Objectives:
The purpose of this study was to determine the effect of nonculprit-lesion PCI timing on major CV outcomes and also the time course of the benefit of complete revascularization.
Methods:
Following culprit-lesion PCI, 4,041 patients with STEMI and multivessel CAD were randomized to staged nonculprit-lesion PCI or culprit-lesion only PCI. Randomization was stratified according to investigator-planned timing of nonculprit-lesion PCI: during or after the index hospitalization. The first coprimary outcome was the composite of CV death or myocardial infarction (MI). In pre-specified analyses, hazard ratios (HRs) were calculated for each time stratum. Landmark analyses of the entire population were performed within 45 days and after 45 days.
Results:
For nonculprit-lesion PCI planned during the index hospitalization (actual time: median 1 day), CV death or MI was reduced with complete revascularization compared with culprit-lesion only PCI (HR: 0.77; 95% confidence interval [CI]: 0.59 to 1.00). For nonculprit lesion PCI planned to occur after hospital discharge (actual time: median 23 days), CV death or MI was also reduced with complete revascularization (HR: 0.69; 95% CI: 0.49 to 0.97; interaction p = 0.62). Landmark analyses demonstrated an HR of 0.86 (95% CI: 0.59 to 1.24) during the first 45 days and 0.69 (95% CI: 0.54 to 0.89) from 45 days to the end of follow-up for intended nonculprit lesion PCI versus culprit lesion only PCI.
Conclusions:
Among STEMI patients with multivessel disease, the benefit of complete revascularization over culprit-lesion only PCI was consistent irrespective of the investigator-determined timing of nonculprit-lesion intervention. The benefit of complete revascularization on hard clinical outcomes emerged mainly over the long term.
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