Complete revascularization effective regardless of reperfusion mode
For patients with STEMI and multivessel CAD, complete revascularization reduced major CV events regardless of whether the primary mode of reperfusion was pharmacoinvasive or primary PCI, according to new data from the COMPLETE trial.
As previously reported by Healio, the COMPLETE trial showed superior outcomes for complete revascularization compared with culprit lesion-only PCI in patients with STEMI and multivessel CAD. In the new substudy, Payam Dehghani, MD, co-director of Prairie Vascular Research Inc. and associate professor at the University of Saskatchewan, Canada, and colleagues examined whether there was a consistent benefit with complete revascularization in patients undergoing a pharmacoinvasive strategy compared with primary PCI.
After performing culprit lesion PCI, Dehghani and colleagues randomly assigned 4,041 patients with STEMI and multivessel CAD to complete revascularization (n = 2,016) or culprit lesion-only PCI (n = 2,025). The researchers performed a prespecified analysis to assess treatment effect in 3,738 patients undergoing primary PCI and 303 patients receiving a pharmacoinvasive strategy, which comprised all of those who received fibrinolysis.
The first coprimary outcome was CV death or new MI, and the second coprimary outcome was CV death, new MI or ischemia-driven revascularization.
According to results, complete revascularization lowered the first coprimary endpoint in patients undergoing a pharmacoinvasive strategy (per year: 2.1% vs. 4.7%; HR = 0.45; 95% CI, 0.21-0.97) and those receiving primary PCI (per year: 2.7% vs. 3.6%; HR = 0.77; 95% CI, 0.62-0.95; P for interaction = .18).
Similarly, the second coprimary outcome also decreased with complete revascularization in patients undergoing a pharmacoinvasive strategy (per year: 2.3% vs. 8.5%; HR = 0.28; 95% CI, 0.14-0.56) and those receiving primary PCI (per year: 3.2% vs. 6%; HR = 0.53; 95% CI, 0.44-0.64; P for interaction P = .07).
In other data, patients who received a pharmacoinvasive strategy compared with primary PCI as the primary reperfusion mode had a lower culprit lesion-specific SYNTAX score; shorter ischemic time; a higher prevalence of TIMI II/III at index PCI; and a less likelihood of hospital discharge on potent P2Y12 inhibitors.
“Although we did not make direct comparisons of clinical outcomes between pharmacoinvasive strategy and primary PCI groups in our analysis, it is reassuring that the differences in characteristics between the two groups did not confound the overall benefit of complete revascularization as observed in the overall trial,” the researchers wrote.
They added that potential reasons for favorable outcomes in the pharmacoinvasive arm include the high rate of early angiography (60% had angiography within 12 hours of STEMI); the optimization of medical therapy (nearly 100% were discharged on dual antiplatelet therapy); and the established track record from registries and meta-analysis supporting excellent clinical outcomes in patients with initial fibrinolysis strategy coupled with early angiography.
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