Complete revascularization of nonculprit lesions offers a greater reduction of cardiovascular (CV) risk in patients with myocardial infarction (MI) or with multivessel coronary artery disease compared with percutaneous coronary intervention (PCI) performed on culprit lesions only, according to study results published in the New England Journal of Medicine.
The researchers sought to determine whether PCI of all suitable nonculprit lesions can further reduce the risk for death from CV causes and new myocardial infarction with ST-segment elevation myocardial infarction (STEMI).
The study included 4041 patients with STEMI and multivessel coronary artery disease from 140 centers in 31 countries who researchers randomly assigned to receive complete revascularization (n=2016) or PCI of the culprit lesion only (n=2025). Randomization occurred within 72 hours of successful treatment of the culprit lesion PCI; investigators stratified participants according to the intended timing of the nonculprit lesion PCI: either during or after the index hospitalization for culprit lesion PCI. Researchers followed all participants for a mean of 36.2 months. The investigators specified 2 primary outcomes: The first was the composite of death from CV causes or new MI, and the second was composite of death from CV causes, new MI, or ischemia-driven revascularization.
The first coprimary outcome occurred in 7.8% of the complete-revascularization group vs 10.5% in the culprit-lesion-only PCI group (hazard ratio [HR] 0.74; 95% CI, 0.6-0.91; P =.004). The second coprimary outcome occurred in 8.9% of the complete-revascularization group vs 16.7% in the culprit-lesion-only PCI group (HR 0.51; 95% CI, 0.43-0.61; P <.001). For both outcomes, complete revascularization of nonculprit lesions consistently benefited patients with STEMI regardless of intended timing of the nonculprit-lesion PCI (first coprimary outcome, P =.62; second coprimary outcome, P =.27).
A limitation of the study was that nonculprit lesion PCIs performed during index PCI procedures were not evaluated. Patients with cardiogenic shock were excluded from the study; therefore, the findings cannot be extrapolated to this patient population. Finally, >90% of patients in the complete vascularization group achieved complete vascularization, and only 4.7% of patients from the culprit-lesion-only group crossed over to the nonculprit lesion strategy, which may have affected the study findings.
The researchers suggested that a strategy of routine nonculprit lesion PCI with a goal of complete revascularization is superior to culprit-lesion-only PCI for reducing risk for death from CV causes and new MI in patients with STEMI and multivessel coronary artery disease.
Mehta SR, Wood DA, Storey RF, et a. Complete revascularization with multivessel PCI for myocardial infarction [published online September 1, 2019]. N Engl J Med. doi:10.1056/NEJMoa1907775