Left Anterior Descending Nonculprit Lesions and Clinical Outcomes in Patients With ST-Segment Elevation Myocardial
Brian P McGrath1, Natalia Pinilla-Echeverri1, David A Wood2
1Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.
Insights
Complete revascularization benefits STEMI patients with multivessel disease, regardless of a proximal LAD nonculprit lesion. The COMPLETE trial found similar outcomes and treatment effects in patients with or without this specific lesion.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- The COMPLETE trial demonstrated benefits of complete revascularization over culprit-only PCI in ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease (MVD).
- The impact of a nonculprit lesion (NCL) in the proximal or mid-left anterior descending (LAD) artery on clinical outcomes in STEMI patients with MVD was previously unclear.
Purpose of the Study:
- To compare cardiovascular outcomes in STEMI patients with MVD based on the location of a proximal/mid-LAD NCL versus other NCL locations.
- To evaluate the benefit of nonculprit lesion revascularization in patients with and without a proximal/mid-LAD NCL.
Main Methods:
- A prespecified subanalysis of the COMPLETE trial involving 4,041 STEMI patients with MVD.
- Patients were treated with either complete revascularization or culprit lesion-only percutaneous coronary intervention (PCI).
- Cox proportional hazards models assessed treatment effects, incorporating an interaction term for treatment allocation and NCL location (proximal/mid-LAD vs. other).
Main Results:
- Of 4,041 patients, 1,666 (41.2%) had a proximal/mid-LAD NCL.
- Event rates for the first coprimary outcome (cardiovascular death or new myocardial infarction) were similar between patients with (8.5%) and without (9.9%) a proximal/mid-LAD NCL.
- Complete revascularization provided similar benefits in reducing the first coprimary outcome for both groups (with NCL HR: 0.85; without NCL HR: 0.65), with no significant interaction (P = 0.235).
Conclusions:
- STEMI patients with multivessel disease and a proximal/mid-LAD NCL exhibit similar event rates compared to those without this lesion.
- The clinical benefit of complete revascularization is consistent across STEMI patients with MVD, irrespective of the presence or location of a nonculprit LAD lesion.
- No evidence of heterogeneity in treatment effect was observed, supporting a uniform approach to complete revascularization in this population.
Background:
In the COMPLETE (Complete vs Culprit-Only Revascularization to Treat Multi-Vessel Disease After Early PCI for STEMI) trial, complete revascularization in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) reduced important outcomes compared with culprit-only percutaneous coronary intervention. Whether clinical outcomes in STEMI patients with MVD are influenced by the presence of a left anterior descending (LAD) nonculprit lesion (NCL) remains unknown.
Objectives:
This study sought to compare: 1) cardiovascular outcomes among patients with an NCL in the proximal/mid-LAD to patients with an NCL in other locations; and 2) the benefit of NCL revascularization in patients with and without a proximal/mid-LAD NCL.
Methods:
The COMPLETE trial enrolled patients presenting with STEMI and MVD to angiography-guided complete revascularization vs a culprit lesion-only strategy. All coronary angiograms were evaluated in a central core laboratory. In this prespecified subanalysis, treatment effect according to proximal/mid-NCL location was determined for the coprimary outcomes of: 1) cardiovascular death or new myocardial infarction; and 2) cardiovascular death, new myocardial infarction, or ischemia-driven revascularization. Cox proportional hazards models were performed with an interaction term for treatment allocation and NCL location.
Results:
Of the 4,041 subjects in COMPLETE, 1,666 patients had a proximal/mid-LAD NCL (41.2%). The first coprimary outcome occurred in 8.5% (2.9%/y) of patients with a proximal/mid-LAD NCL vs 9.9% (3.4%/y) in those without (adjusted HR: 0.83; 95% CI: 0.67-1.03). Complete revascularization had a similar benefit in reducing the first coprimary outcome for patients with a proximal/mid-LAD NCL (7.7% vs 9.2%; HR: 0.85; 95% CI: 0.61-1.18) and those without (8.0% vs 11.9%; HR: 0.65; 95% CI: 0.50-0.86), with no differential treatment effect (interaction P = 0.235) CONCLUSIONS: Among patients presenting with STEMI and multivessel CAD, those with a proximal/mid-LAD NCL had similar event rates to those without. The benefit of complete revascularization between the groups was similar, with no evidence of heterogeneity.
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