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Nonculprit Lesion Severity and Outcome of Revascularization in Patients With STEMI and Multivessel Coronary Disease
Tej Sheth1, Natalia Pinilla-Echeverri2, Raul Moreno3
1Population Health Research Institute, Hamilton, Ontario, Canada; McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada. Electronic address: https://twitter.com/PHRIresearch.
Insights
Complete revascularization significantly reduced cardiovascular events in ST-segment elevation myocardial infarction patients with multivessel coronary artery disease. The benefit was greater for lesions with stenosis severity ≥60% compared to <60%.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- The COMPLETE trial demonstrated that complete revascularization reduces major cardiovascular (CV) events in ST-segment elevation myocardial infarction (MI) patients with multivessel coronary artery disease.
- Percutaneous coronary intervention (PCI) of nonculprit lesions was guided by angiography.
Purpose of the Study:
- To evaluate the impact of nonculprit-lesion stenosis severity, measured by quantitative coronary angiography (QCA), on the effectiveness of complete revascularization.
- To determine if QCA-measured stenosis severity influences the benefit of complete revascularization in STEMI patients.
Main Methods:
- Quantitative coronary angiography (QCA) assessed nonculprit lesion stenosis severity in 3,851 patients from the COMPLETE trial.
- Pre-specified analyses compared treatment effects for QCA stenosis ≥60% versus <60% on two co-primary outcomes.
Main Results:
- Complete revascularization reduced the first co-primary outcome (CV death or new MI) in patients with QCA stenosis ≥60% (HR: 0.61) but not <60% (HR: 1.04; interaction p=0.02).
- The second co-primary outcome (CV death, new MI, or ischemia-driven revascularization) was significantly reduced in patients with QCA stenosis ≥60% (HR: 0.43) compared to <60% (HR: 0.65; interaction p=0.04).
Conclusions:
- Complete revascularization provides greater benefits in reducing major CV outcomes for patients with ST-segment elevation MI and multivessel coronary artery disease when nonculprit lesions have ≥60% stenosis.
- Stenosis severity, as determined by QCA, is a critical factor in the benefit derived from complete revascularization in this patient population.
Background:
In the COMPLETE (Complete vs Culprit-only Revascularization to Treat Multi-vessel Disease After Early PCI for STEMI) trial, angiography-guided percutaneous coronary intervention (PCI) of nonculprit lesions with the aim of complete revascularization reduced major cardiovascular (CV) events in patients with ST-segment elevation myocardial infarction (MI) and multivessel coronary artery disease.
Objectives:
The purpose of this study was to determine the effect of nonculprit-lesion stenosis severity measured by quantitative coronary angiography (QCA) on the benefit of complete revascularization.
Methods:
Among 4,041 patients randomized in the COMPLETE trial, nonculprit lesion stenosis severity was measured using QCA in the angiographic core laboratory in 3,851 patients with 5,355 nonculprit lesions. In pre-specified analyses, the treatment effect in patients with QCA stenosis ≥60% versus <60% on the first coprimary outcome of CV death or new MI and the second co-primary outcome of CV death, new MI, or ischemia-driven revascularization was determined.
Results:
The first coprimary outcome was reduced with complete revascularization in the 2,479 patients with QCA stenosis ≥60% (2.5%/year vs. 4.2%/year; hazard ratio [HR]: 0.61; 95% confidence interval [CI]: 0.47 to 0.79), but not in the 1,372 patients with QCA stenosis <60% (3.0%/year vs. 2.9%/year; HR: 1.04; 95% CI: 0.72 to 1.50; interaction p = 0.02). The second coprimary outcome was reduced in patients with QCA stenosis ≥60% (2.9%/year vs. 6.9%/year; HR: 0.43; 95% CI: 0.34 to 0.54) to a greater extent than patients with QCA stenosis <60% (3.3%/year vs. 5.2%/year; HR: 0.65; 95% CI: 0.47 to 0.89; interaction p = 0.04).
Conclusions:
Among patients with ST-segment elevation MI and multivessel coronary artery disease, complete revascularization reduced major CV outcomes to a greater extent in patients with stenosis severity of ≥60% compared with <60%, as determined by quantitative coronary angiography.
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