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Complete revascularisation superior to culprit-lesion-only PCI

ESC 2019
Patients with STEMI and multivessel coronary artery disease achieve more benefit from complete revascularisation than from culprit-lesion-only PCI with regard to reducing the risk of CV death or MI.

The COMPLETE trial randomised 4,041 patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI) and had non-culprit multivessel coronary disease (defined as a 70% stenosis or 50-69% stenosis with fractional flow reserve ≤0.8). Exclusion criteria were planned revascularisation of non-culprit lesion, planned surgical revascularisation, non-cardiovascular co-morbidity reducing life expectancy to <5 years, prior coronary artery bypass graft (CABG) surgery, and any factor precluding 5-year follow-up. Mean patient age was 62 years, 19% was female, 19% of patients had diabetes, and follow-up was 3 years. Primary endpoint was cardiovascular death or myocardial infarction; this occurred in 7.8% of the complete revascularisation group compared with 10.5% of the culprit-only revascularisation group (P=0.004). This outcome was the same when PCI was performed during or after the index hospitalisation (P for interaction=0.62). Secondary outcomes included cardiovascular death, myocardial infarction, or ischaemia-driven revascularisation (8.9% vs 16.7%, P<0.001 respectively), major bleeding (2.9% vs 2.2%; P=0.15 respectively), and contrast-induced nephropathy (1.5% vs 0.9%, P=0.11 respectively).

Thus, the researchers concluded that complete revascularisation was superior to culprit-only revascularisation in patients with STEMI and multivessel disease who underwent primary PCI. Complete revascularisation was associated with a reduction in cardiovascular death or myocardial infarction while no increase was observed in major bleeding or contrast-induced nephropathy. Although previous trials had already demonstrated benefit for complete revascularisation, this was largely due to a reduction in the risk of revascularisation. The value of the COMPLETE trial lies in the fact that it was able to show that complete revascularisation was associated with a reduction in ‘hard outcomes’, as the primary outcome was cardiovascular death or myocardial infarction. [1]

1. Mehta SR, et al. COMPLETE Revascularization with Multivessel Percutaneous Coronary Intervention in ST-segment Elevation Myocardial Infarction. FP Number 2104. ESC Congress 2019, 31 Aug-4 Sept, Paris, France.

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