Timing of Staged Nonculprit Artery Revascularization in Patients With ST-Segment Elevation Myocardial Infarction
David WoodJohn A. CairnsJia WangRoxana MehranRobert F. StoreyHelen NguyenBrandi MeeksVijay KunadianJean‐François TanguayHahn-Ho KimAsim N. CheemaPayam DehghaniMadhu K. NatarajanSanjit S. JollyJohn AmerenaMátyás KeltaiStefan JamesOta HlinomazKari NiemeläKhalid F. AlHabibBasil S. LewisMichel NguyenJaydeep SarmaVladimír DžavíkAnthony Della SiegaShamir R. Mehta
Key result
Complete revascularization reduces CV death or MI ~23%, regardless of index or post-discharge timing.
- HR 0.77
- 95% CI 0.59-1.00
- n=4,041
Why the study?
The effect of timing of staged nonculprit-lesion PCI on major cardiovascular outcomes and the time course of benefit of complete revascularization in STEMI patients with multivessel CAD was uncertain.
Does complete revascularization via staged nonculprit-lesion PCI reduce CV death or MI compared to culprit-lesion only PCI in STEMI patients with multivessel CAD, and does the timing of the procedure affect this benefit?
Study Design
Type
RCT (n=4,041)
Randomization
Stratified according to investigator-planned timing
Structured PICO
Does complete revascularization via staged nonculprit-lesion PCI reduce CV death or MI compared to culprit-lesion only PCI in STEMI patients with multivessel CAD, and does the timing of the procedure affect this benefit?
P
Population
4,041 patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease.
I
Intervention
Staged nonculprit-lesion PCI (complete revascularization) planned either during the index hospitalization (actual median 1 day) or after hospital discharge (actual median 23 days)
C
Comparator
Culprit-lesion only PCI
O
Outcome
Composite of cardiovascular (CV) death or myocardial infarction (MI)composite
Main Result
Hazard Ratio: 0.77 (95% CI 0.59–1)
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“The most important goal of primary PCI is to open the infarct-related artery and establish perfusion to the ischemic myocardium. It's not to open the nonculprit artery. We know that primary PCI is a lifesaving procedure and that should be the focus.”
Implication
Complete revascularization reduces hard clinical outcomes in STEMI patients with multivessel disease consistently, whether the staged nonculprit-lesion PCI is performed during the index hospitalization or after discharge.
Abstract
BACKGROUND The COMPLETE (Complete vs Culprit-only Revascularization to Treat Multi-vessel Disease After Early PCI for STEMI) trial demonstrated that staged nonculprit lesion percutaneous coronary intervention (PCI) reduced major cardiovascular (CV) events in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD). OBJECTIVES The purpose of this study was to determine the effect of nonculprit-lesion PCI timing on major CV outcomes and also the time course of the benefit of complete revascularization. METHODS Following culprit-lesion PCI, 4,041 patients with STEMI and multivessel CAD were randomized to staged nonculprit-lesion PCI or culprit-lesion only PCI. Randomization was stratified according to investigator-planned timing of nonculprit-lesion PCI: during or after the index hospitalization. The first coprimary outcome was the composite of CV death or myocardial infarction (MI). In pre-specified analyses, hazard ratios (HRs) were calculated for each time stratum. Landmark analyses of the entire population were performed within 45 days and after 45 days. RESULTS For nonculprit-lesion PCI planned during the index hospitalization (actual time: median 1 day), CV death or MI was reduced with complete revascularization compared with culprit-lesion only PCI (HR: 0.77; 95% confidence interval [CI]: 0.59 to 1.00). For nonculprit lesion PCI planned to occur after hospital discharge (actual time: median 23 days), CV death or MI was also reduced with complete revascularization (HR: 0.69; 95% CI: 0.49 to 0.97; interaction p = 0.62). Landmark analyses demonstrated an HR of 0.86 (95% CI: 0.59 to 1.24) during the first 45 days and 0.69 (95% CI: 0.54 to 0.89) from 45 days to the end of follow-up for intended nonculprit lesion PCI versus culprit lesion only PCI. CONCLUSIONS Among STEMI patients with multivessel disease, the benefit of complete revascularization over culprit-lesion only PCI was consistent irrespective of the investigator-determined timing of nonculprit-lesion intervention. The benefit of complete revascularization on hard clinical outcomes emerged mainly over the long term.
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Cite This Study
Wood et al. (2019) conducted an RCT in ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (n=4,041). Staged nonculprit-lesion percutaneous coronary intervention vs. Culprit-lesion only PCI was evaluated on Composite of cardiovascular death or myocardial infarction (HR 0.77, 95% CI 0.59-1.00). Complete revascularization over culprit-only PCI for CV death or MI was consistent whether planned during index hospitalization (HR 0.77) or after discharge (HR 0.69).