Complete Revascularization Beneficial in STEMI and Multivessel Disease – The Cardiology Advisor

Complete revascularization has demonstrated consistent long-term benefit over culprit-lesion-only percutaneous coronary intervention (PCI) among patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease, regardless of nonculprit-lesion intervention timing. This research was recently published in the Journal of the American College of Cardiology.

This study included 4041 individuals with multivessel coronary artery disease and STEMI, 49.9% (n=2016) of whom were randomly assigned to nonculprit-lesion PCI and 50.1% (n=2025) of whom were randomly assigned to culprit-lesion-only PCI. The investigators intended timing of nonculprit-lesion PCI (during vs after index STEMI hospitalization) was used to stratify randomization. Coprimary outcomes included first incidence of composite cardiovascular mortality or myocardial infarction. Researchers assessed the difference in treatment effect between complete revascularization and culprit-lesion-only PCI, as well as the time to observation of benefit. Hazard ratios (HRs) were computed for each category of time. To assess the coprimary outcome rates, landmark analyses were performed within 45 days of random assignment and after 45 days.

Among those with intended PCI during index STEMI hospitalization, complete revascularization was associated with a lower rate of first coprimary outcome compared with culprit-lesion-only PCI (2.7% vs 3.5%, respectively; HR, 0.77; 95% CI, 0.59-1.00). A similar result was observed among those with intended nonculprit PCI following index hospitalization (2.7% vs 3.9%, respectively; HR 0.69; 95% CI, 0.49-0.97). The effect of timing on the first coprimary outcome was not significant (P =.62).

In the period of initial 45 days, landmark analysis of intended nonculprit-lesion PCI vs culprit-lesion-only PCI yielded an HR of 0.86 (95% CI, 0.59-1.24), while landmark analysis from after 45 days to a median follow-up of 3 years (end of study) yielded an HR of 0.69 (95% CI, 0.54-0.89).

Limitations to this study included an inability to assess nonculprit-lesion PCI undertaken during the STEMI procedure, a lack of information on rationale behind timing of nonculprit PCI, potential bias in timing of nonculprit-lesion PCI, and insufficient power to identify subgroup-level differences within nonculprit PCI categories.

The researchers concluded that the benefit of complete revascularization over culprit-lesion only PCI was consistent irrespective of the investigator-determined timing of nonculprit lesion intervention. Nonculprit PCI presented no major safety concerns, and the main benefit of nonculprit PCI seems to emerge over the long term.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors disclosures.

Reference

Wood DA, Cairns JA, Wang J, et al; for the COMPLETE Investigators. Timing of staged nonculprit artery revascularization in patients with ST-segment elevation myocardial infarction. J Am Coll Cardiol. 2019;74:2713-2723.

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Complete Revascularization Beneficial in STEMI and Multivessel Disease - The Cardiology Advisor