Complete revascularisation improves STEMI outcome

Wednesday, September 3, 2014

Complete Revascularisation Improves STEMI OutcomeComplete revascularisation was associated with a better outcome for MI patients with lesions in the non-infarct related artery (N-IRA) than intervention in the culprit artery alone.
Indeed, current ESC and AHA/ACC guidelines recommend treating the infarct-related artery (IRA) only. But findings from the Complete versus Lesion-only PRimary PCI Trial (CvLPRIT) presented at a Hot Line session on Monday may prove practice changing. The study found a 55% reduction in MACE in those patients presenting for primary PCI when the N-IRA was also treated on admission.   
Anthony Gershlick, principal investigator of CvLPRIT, said the results ‘suggest strongly’ that all lesions be treated before the patient is discharged. ‘The results demonstrate a statistically significant benefit from a strategy of complete revascularisation. The early separation of the curves in CvLPRIT suggests a delayed staged out-patient complete strategy may not be as effective,’ said Gershlick, from Glenfield Hospital, Leicester, UK.
The question of whether to treat angiographically significant stenoses in N-IRA on admission for MI remains unresolved. Retrospective registry studies suggest not. However, findings from the PRAMI study of 2013 showed a 65% reduction in MACE with total revascularisation at the time of primary PCI. Gershlick noted that there has since been criticism of the trial design, as a result of which PRAMI did not lead to widespread changes in clinical practice.
Designed differently from PRAMI, the CvLPRIT study compared IRA-only treatment during index admission with complete revascularisation, with a primary endpoint of MACE. 
A total of 296 MI patients presenting at seven UK interventional centres were randomised before PCI - one group to IRA-only revascularisation (n=146) and the other to complete revascularisation of both the IRA and all N-IRAs shown to be significantly blocked (n=150). 

For those in the complete revascularisation group, the IRA was treated first followed by the N-IRAs. This was during the same index hospital admission, preferably in the same sitting.
The findings showed that one year after the procedure, patients in the complete revascularisation group had significantly better outcomes than those who had only their IRA revascularised. These results were based on the composite endpoint of MACE, which occurred in 21.2% of the IRA-only arm versus 10.0% of the complete revascularisation group (HR 0.45%, p=0.009). 
Not surprisingly, procedure time and contrast volume load were significantly higher in the complete revascularisation group than in the  IRA-only group (55 vs 41 mins, p=0.0001; and 250 vs 190 mls, p<0.0001 respectively). But despite this the complete revascularisation patients had no increase in stroke, major bleeding or contrast-induced nephropathy.   
Steen Dalby Kristensen, ESC spokesperson, said the CvLPRIT results would be considered ‘carefully’. ‘It’s better we do something with the lesions than not do anything,’ he commented. ‘The question is when to do it. We still need to find out if this is as good as doing it immediately.’