Is Complete Revascularization the Right Choice in Acute Myocardial Infarction with Multivessel Disease?

Courtesy of Dr. Carlos Fava.

Primary coronary angioplasty has been the treatment of choice for acute myocardial infarction (MI) for many years, but such strategy is associated with nonculprit lesions in a large group of patients. While it has been proven that nonculprit-lesion revascularization offers better outcomes, the groups that would benefit from it are still unclear.

This study included patients who had undergone primary angioplasty. Patients with lesions >70% according to visual assessment or 50%-69% and fractional flow reserve (FFR) ≤0.80 were randomized to undergo revascularization or receive medical treatment.

Consequently, 4041 patients were studied. Among them, 2016 underwent complete revascularization (CR) and 2025 underwent culprit-lesion revascularization (CLR).

The first coprimary endpoint (FCE) was the composite of cardiovascular death or new acute MI, and the second coprimary endpoint (SCE) was the composite of cardiovascular death, new acute (MI), or ischemia-driven revascularization.

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Groups had similar results, without any differences.

Within 45 days, there was a 4.7% crossover from the CLR group to the CR group, and a 3.9% crossover from the CR group to the CLR group.

After a 3-year follow-up, the FCE was in favor of CR: 7.8% vs. 10.5% (hazard ratio: 0.74; 95% confidence interval [CI]: 0.60 to 0.91; p = 0.004). This was due to lower rates of death and new acute MI (2.9% vs. 3.2%, and 5.4% vs. 7.9%). In the meantime, SCE figures also favored CR: 8.9% vs. 16.7% (hazard ratio: 0.51; 95% CI: 0.43 to 0.61; p < 0.001).

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There were no differences as regards stent thrombosis, major bleeding, and stroke.

Conclusion

Among patients with acute myocardial infarction and multivessel disease, complete revascularization was superior to culprit-lesion-only revascularization in reducing the risk of cardiovascular death and new myocardial infarction, as well as in ischemia-driven revascularization.

Courtesy of Dr. Carlos Fava.

Original title: Complete Revascularization with Multivessel PCI for Myocardial Infarction. COMPLETE Trial Steering Committee and Investigators.

Reference: Shamir R. Mehta, et al. N Engl J Med Sep 1 DOI: 10.1056/NEJMoa1907775.

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