27th October 2019. Dr Chee L Khoo
Imagine you are the interventional cardiologist. You are asked to perform a percutaneous coronary intervention for a symptomatic coronary artery stenosis with a view of inserting a stent for the tight stenotic lesion. As the coronary angiogram is being performed, you discover that there are more than one stenotic lesion. Do you stent the symptomatic lesion alone as was originally intended or do you stent all the other incidentally found stenotic lesions? Is there a difference in cardiovascular outcomes between the two options? I mean, if stenting more lesions do not improve cardiovascular outcomes, why should you stent more than what you intended to?
Patients who has a ST-elevation myocardial infarct (STEMI) often have multivessel disease in addition to the culprit lesion causing the STEMI. Non-culprit lesions are commonly discovered incidentally at the time of the PCI. It is often a dilemma for interventional cardiologists whether to routinely revascularise (stent) the non-culprit lesions as it is thought these lesions may represent stable coronary artery plaques and revascularisation may not result in benefit.
The Complete versus Culprit-Only Revascularization Strategies to Treat Multivessel Disease after Early PCI for STEMI (COMPLETE) trial was designed to explore whether revascularisaton of non-culprit lesion at PCI reduces risk of death from cardiovascular causes or myocardial infarction. This was a multi-national randomised trial of patients who presented with a STEMI and had multivessel coronary disease. These subjects underwent randomisation within 72 hours to either undergo further PCI for a complete revascularisation (of the other non-culprit lesions) or received guideline-based medical treatment after PCI of the culprit lesion only. Non-culprit lesions were deemed angiographically significant if they were associated with at least 70% stenosis of the vessel diameter on visual estimation.
Guideline-based medical treatment for both groups consists of dual antiplatelet therapy with aspirin and ticagrelor for at least 1 year was recommended.22 Beyond 1 year, aspirin was recommended for all patients, and ticagrelor (60 mg twice daily) was recommended for patients who were not at high risk for bleeding.
From February 1, 2013, through March 6, 2017, a total of 4041 patients from 140 centers in 31 countries underwent randomisation: 2016 were assigned to the complete-revascularisation group and 2025 to the culprit-lesion-only PCI group. The first co-primary outcome was the composite of cardiovascular death or myocardial infarction; the second co-primary outcome was the composite of cardiovascular death, myocardial infarction, or ischaemia-driven revascularisation.
At a median follow up of 3 years, the primary outcome occurred in 7.8% of the complete revascularisation group compared with 10.5% in the culprit lesion PCI group (hazard ratio of 0.74, p=0.004). The secondary outcome occurred in 8.9% of the complete revascularisation group compared with 16.7% in the culprit lesion PCI group (hazard ratio of 0.51, p<0.001).
The authors concluded that “Among patients with STEMI and multivessel coronary artery disease, complete revascularization was superior to culprit-lesion-only PCI in reducing the risk of cardiovascular death or myocardial infarction, as well as the risk of cardiovascular death, myocardial infarction, or ischemia-driven revascularization.”
So, the next time your patient undergoes PCI and ended up with more stents than he or she bargain for, it’s a good thing.
Access the abstract here.
Mehta S, Wood D, Storey R, et al. Complete Revascularization with Multivessel PCI for Myocardial Infarction. N Engl J Med 2019;381:1411-21.