Original title: Randomized Trial of Complete Versus Lesion-Only Revascularization in Patients Undergoing Primary Percutaneous Coronary Intervention for STEMI and Multivessel Disease: The CvLPRIT Trial. Reference: Gershlick AH et al. J Am Coll Cardiol. 2015 Mar 17;65(10):963-72.
Recent studies such as the PRAMI and the one we summarize here show complete revascularization of AMI patients before discharge could be a safe strategy and even a beneficial. Observational studies have shown the opposite.
This study randomized 296 patients after primary PCI. It compared outcomes of 146 patients receiving infarct related artery (IRA) only PCI vs. 150 patients receiving complete revascularization, either at the time of primary PCI or prior to discharge, according to the operator’s criterion. The second group included cases when the IRA was the first lesion treated and all other severe lesions were also treated. Patients with OCT as only non-culprit lesion were excluded.
Primary end point was a composite of all cause death, recurrent infarction, heart failure, and ischemia driven revascularization within 12 months. Secondary end points were any of primary end point outcomes and cardiovascular death. Safety end points were stroke, major bleeding and contrast induced nephropathy (CIN).
Angiographic and clinical population characteristics were similar. From the CR group, a 7% received IRA only PCI an almost 2% received CABG. 64% of CR group patients completed revascularization at the time of primary PCI.
Combined end point was significantly lower in the CR arm (10%) compared to the IRA only arm (21.2%), p = 0.009. Secondary end points were also lower but with no statistical importance. The rates of stroke, CIN and bleeding were similar. There were also less events in patients with CR at primary PCI vs those treated in stages.
Conclusion
This study shows the uncomplicated potential benefit of complete revascularization to treat infarction including non-culprit lesions with a fast separation of combined events curves (p = 0,055 before 30 days).
Editorial Comment
This is small study supporting the hypothesis that states CR reduces ischemic burden, which provides short and medium term protection against new ischemic events. This could be explained partly by the evidence (in the original study) of pan-coronary inflammation during AMI, increasing risk of events in patients with stable lesions. Further randomized studies seem necessary to change the daily practice and define an optimal opportunity (in progress: COMPLETE). SYNTAX scores of both arms would also be interesting to compare.
Courtesy of Drs. Santiago Alonso and Pablo Vazquez.
Centro Cardiológico Americano. Sanatorio Americano.
Montevideo, Uruguay.
Dres. Santiago Alonso y Pablo Vazquez