September 1st, 2014
New Support For Complete Revascularization During Primary PCI
Until recently, MI patients receiving emergency PCI would only have the culprit artery opened. Complete revascularization of non-infarct-related arteries was performed later. The conventional wisdom was that revascularization of non-infarct-related arteries could be dangerous. That wisdom began to change last year with the PRAMI trial, which found no evidence of harm and a suggestion of benefit in MI patients who underwent more complete revascularization.
Now a new study presented at the European Society of Cardiology meeting in Barcelona delivers additional support to the more liberal use of total revascularization during initial treatment. The CvLPRIT (The Complete versus Lesion-only Primary PCI Trial) was an open-label, randomized study comparing treatment of the infarct-related artery (IRA) only with complete revascularization in 296 acute MI patients.
At 12 months, there was a large and statistically significant reduction in the incidence of major adverse cardiac events in the group randomized to complete revascularization. Each of the endpoint components was also numerically lower in the complete revascularization arm:
- MACE: 21.2% in the IRA arm versus 10% in the complete revascularization arm, HR 0.45, CI 0.24-0.84, p=0.009
- Mortality: 4.1% versus 1.3%, HR 0.32, ).06-1.60, p=0.14
- Recurrent MI: 2.7% versus 1.3%, HR 0.48,, 0.09-2.62, p=0.39
- Heart failure: 6.2% versus 2.7%, HR 0.43, 0.13-1.39, p=0.14
- Repeat revascularization: 8.2% versus 4.7%, HR 0.55, 0.22-1.39, p=0.2
The benefits of complete revascularization emerged shortly after the index procedure and were apparent in the prespecified subgroups, including the number of significantly affected vessels, sex, and age.
The authors were encouraged by the fact that hard events were reduced in similar proportion to the softer endpoint of repeat revascularization. The result “suggests this strategy may need to be considered by future STEMI guideline committees,” they said.
The previous PRAMI trial had been criticized because of some trial design issues, said CvLPRIT investigator Anthony Gershlick. “As a result, PRAMI has not led to widespread changes in clinical practice, with IRA-only revascularization at P-PCI remaining by far the more common practice.”
In an interview, Eliot Antman said that he was particularly struck by the apparent lack of harm in the complete revascularization group, since it has been the fear of causing harm that has been the main reason not to perform more complete revascularization. Because of the small size of the trial and the small number of events, he was unsure whether the trial would be enough to change current guideline recommendations.
To view all of our coverage from the ESC meeting, go to our ESC.14 Headquarters page.