ESC 2019 | COMPLETE: Definitive Evidence for Infarction with Multivessel Disease

For patients with ST-segment elevation acute myocardial infarction and multivessel disease beyond the culprit artery, complete revascularization is superior to culprit-only treatment as regards the final endpoint, a composite of cardiovascular death, infarction, and ischemia-driven revascularization over a mean follow-up of 3 years. This information derives from long-awaited randomized study COMPLETE, finally presented at the European Society of Cardiology (ESC) Congress 2019 Scientific Sessions (and simultaneously published in the New England Journal of Medicine [NEJM]).

Complete revascularization was superior, and it should be noticed that its timing did not seem to change the results. With this information, we should withhold from conducting multivessel angioplasties in the wee hours of the morning. Instead, we should only treat the culprit artery and then revascularize the remaining vessels at a second stage, which may be planned for the following day.

The COMPLETE trial randomized 4041 patients with multivessel disease admitted with acute myocardial infarction, who had successful culprit-lesion primary angioplasty, to either undergo further complete revascularization or receive guideline-directed medical therapy alone.

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All patients had multivessel disease with lesions with at least 70% diameter stenosis or fractional flow reserve (FFR) measurements of 0.8 or less. The timing of complete revascularization was left to operator discretion. No patients with cardiogenic shock were included.

The largest number of nonculprit lesions were located in the anterior descending artery (40%), followed by the circumflex, and the right coronary artery.

After a mean follow-up of 3 years, the rates of the primary endpoint (cardiovascular death, new infarction, or ischemia-driven revascularization) were significantly lower for patients who received complete revascularization vs. culprit-only revascularization (7.8% vs 10.5%; hazard ratio [HR]: 0.74; 95% confidence interval [CI]: 0.6 to 0.91).

Results were not affected by the timing of nonculprit angioplasty, whether during the index hospitalization (mean 1 day after the culprit-lesion primary angioplasty) or after discharge (mean 23 days after the primary angioplasty).

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The largest effect of complete revascularization was its benefit on the rate of new infarction, which was reduced by 32%. There were no differences in mortality, but these over 4000 patients did not provide enough statistical power for such endpoint.

As regards whether FFR is needed to decide on the revascularization of nonculprit lesions, the protocol for the COMPLETE trial may have been too hard as far as inclusion criteria go. Nearly 60% of patients had lesions with at least 80% stenosis of the vessel diameter as assessed through angiography, and most of these lesions were in the anterior descending artery. Consequently, in this setting, the coincidence between FFR and angiography was high.

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Original title: Complete revascularization with multivessel PCI for myocardial infarction.

Reference: Mehta SR et al. N Engl J Med. 2019; Epub ahead of print.

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