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Complete revascularization benefits patients with multivessel CAD requiring PCI
SAN DIEGO — Among patients with STEMI and multivessel CAD undergoing primary PCI, those who had complete revascularization had better outcomes than those who had revascularization of the culprit vessel only, according to results of the DANAMI3-PRIMULTI study.
Thomas Engstrøm, MD, DMSci, PhD, and colleagues randomly assigned 627 patients with STEMI and multivessel CAD, defined as more than 50% stenosis in at least one nonculprit lesion of at least 2 mm, to undergo PCI of the culprit lesion only or complete revascularization guided by fractional flow reserve.
Thomas Engstrøm
Approximately 30% to 50% of patients admitted for STEMI have stenoses in vessels other than the infarct-related artery, Engstrøm said during a press conference at the American College of Cardiology Scientific Sessions. “Guidelines have previously supported that you [revascularize] only the culprit vessel and leave the other vessels untreated, but two very recent studies suggest a benefit for revascularization of all the coronary arteries,” said Engstrøm, chief consultant, department of invasive cardiology, Rigshospitalet, University of Copenhagen, Denmark.
The primary endpoint of the DANAMI3-PRIMULTI study was a composite of all-cause mortality, nonfatal MI and ischemia-driven revascularization of nonculprit lesions. All patients were followed for at least 1 year.
Compared with PCI of the culprit lesion only, patients assigned complete revascularization had a lower risk for the primary endpoint (HR = 0.56; 95% CI, 0.38-0.83).
The results were driven by ischemia-driven revascularization of nonculprit lesions (HR = 0.31; 95% CI, 0.18-0.53), Engstrøm said.
There was no difference between the groups in nonfatal MI (HR = 0.94; 95% CI, 0.47-1.9) or all-cause death (HR = 1.4; 95% CI, 0.63-3).
“Complete FFR-guided revascularization of multivessel disease in STEMI patients reduces the primary endpoint of all-cause death, reinfarction and complete revascularization, but we acknowledge also that this endpoint was not driven by hard endpoints,” he said. “Having said that, it turned out that 40% of the repeat revascularizations were urgent on the basis of unstable angina.” – by Erik Swain
Reference:
Engstrøm T. Late-Breaking Clinical Trials V: TCT@ACC-i2 Interventional Cardiology. Presented at: American College of Cardiology Scientific Sessions; March 14-16, 2015; San Diego.
Disclosure: Engstrøm reports receiving consulting fees/honoraria from Eli Lilly, Novo Nordisk, Servier and New Zealand Pharma.
Perspective
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Despite complete revascularization being a class III indication (do not do), the issue of what to do for significant nonculprit artery blockages has been increasingly studied. Two recent studies showed significant benefit of complete revascularization when compared with culprit-only revascularization. This is yet another trial which shows similar results — advantage of complete revascularization over culprit-only — thus questioning the validity of the guideline recommendations. That being said, all three trials showed significant benefit for the reduction in repeat procedures but no difference in harder outcomes of death or MI. We need larger studies to answer the question of whether complete revascularization will indeed reduce the risk for death or MI. Nevertheless, it is time the guidelines are updated to allow for complete revascularization.