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Impact of Revascularization Completeness on Cardiovascular Outcomes in STEMI With Multivessel Disease
Mehdi Madanchi1, Natalia Pinilla-Echeverri1, David A Wood2
1Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (M.M., N.P.-E., T.S., H.N., T.M., S.R.M.).
Insights
Complete revascularization after percutaneous coronary intervention (PCI) for ST-segment-elevation myocardial infarction is beneficial. Achieving complete revascularization (R'SS=0) significantly reduces major cardiovascular events compared to incomplete revascularization (R'SS>0).
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Clinical Trials
Background:
- Complete revascularization (CR) is superior to culprit lesion-only percutaneous coronary intervention (PCI) for reducing ischemic events in ST-segment-elevation myocardial infarction (STEMI) with multivessel disease.
- The precise relationship between the degree of anatomic completeness of revascularization and the benefits of CR remains unclear.
- The modified residual SYNTAX score (R'SS) is a measure of the anatomic completeness of revascularization.
Purpose of the Study:
- To evaluate how the degree of anatomic completeness of revascularization, measured by the R'SS, relates to major cardiovascular events in STEMI patients with multivessel disease.
- To explore the impact of achieving an R'SS of 0 versus R'SS > 0 within the CR strategy.
Main Methods:
- An exploratory post hoc analysis of the COMPLETE trial (n=3738) was performed.
- Patients randomized to CR were stratified based on R'SS assessed after staged nonculprit lesion-PCI.
- Complete revascularization was defined as R'SS=0; incomplete revascularization was defined as R'SS>0. Cox proportional hazards models were used, comparing to culprit-only PCI.
Main Results:
- Among patients randomized to CR, 90% achieved R'SS=0 and 10% had R'SS>0.
- In the R'SS=0 group, the first coprimary outcome (CV death or MI) occurred less frequently (6.6%) compared to culprit-only PCI (10.7%; aHR, 0.61).
- In the R'SS>0 group, the first coprimary outcome was similar (10.7%) to the culprit-only PCI group (10.7%; aHR, 1.01).
Conclusions:
- The benefit of a complete revascularization strategy in STEMI patients with multivessel disease may be directly related to the anatomic completeness achieved.
- Achieving a residual SYNTAX score of 0 is crucial for realizing the full benefits of complete revascularization.
- Incomplete revascularization (R'SS>0) within a CR strategy does not appear to offer additional benefits over culprit-lesion-only PCI.
Background:
Complete revascularization is superior to culprit lesion-only percutaneous coronary intervention (PCI) in reducing ischemic events in patients with ST-segment-elevation myocardial infarction and multivessel disease. However, the relationship between the extent of revascularization and the benefits of a complete revascularization strategy remains unclear. The aim of this substudy of the COMPLETE trial was to evaluate how the degree of anatomic completeness of revascularization, measured by the core laboratory-derived modified residual SYNTAX score (R'SS), relates to major cardiovascular events.
Methods:
We conducted an exploratory post hoc analysis of the COMPLETE trial (n=3738), stratifying patients randomized in the complete revascularization group based on the R'SS assessed after staged nonculprit lesion-PCI. Complete revascularization was defined by an R'SS=0, whereas incomplete revascularization was defined by an R'SS>0. A stratified Cox proportional hazards model was used, with the culprit-only PCI arm designated as the reference group for comparison. The first coprimary outcome was a composite of cardiovascular death or new myocardial infarction. The second coprimary outcome was a composite of cardiovascular death, new myocardial infarction, or ischemia-driven revascularization.
Results:
Among patients randomized to a complete revascularization strategy, 90% achieved complete revascularization (R'SS=0), whereas 10% did not (R'SS>0). In patients with R'SS=0, the first coprimary outcome occurred less frequently (6.6%) compared with those randomized to the culprit lesion-only PCI strategy (10.7%; adjusted hazard ratio, 0.61 [95% CI, 0.47-0.78]). Among patients with an R'SS>0, the first coprimary outcome was similar (10.7%) to those in the culprit lesion-only PCI group (10.7%; adjusted hazard ratio, 1.01 [95% CI, 0.61-1.67]). A similar result was observed for the second coprimary outcome.
Conclusions:
This exploratory analysis of the COMPLETE trial suggests that the benefit of a complete revascularization strategy in patients with ST-segment-elevation myocardial infarction and multivessel disease may be related to the extent of anatomic completeness of revascularization.
Registration:
URL: https://www.clinicaltrials.gov; Unique identifier: NCT01740479.
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