Complete Versus Lesion-Only Primary PCI

• Published in: Journal of the American College of Cardiology 2015-12, Vol.66 (24), p.2713-2724
• Main Authors: McCann, Gerry P., MD, Khan, Jamal N., MBChB, Greenwood, John P., MBChB, PhD, Nazir, Sheraz, MBBChir, Dalby, Miles, MD, Curzen, Nick, BM, PhD, Hetherington, Simon, MD, Kelly, Damian J., MD, Blackman, Daniel J., MD, Ring, Arne, PhD, Peebles, Charles, MBChB, Wong, Joyce, MD, Sasikaran, Thiagarajah, PhD, Flather, Marcus, MBBS, PhD, Swanton, Howard, MD, Gershlick, Anthony H., MBBS
• Format: Article
• Language: English
• Subjects: Cardiology; Cardiovascular; Cardiovascular disease; Clinical outcomes; CMR; complete revascularization; Confidence intervals; Heart attacks; Heart failure; Internal Medicine; Ischemia; Medical imaging; multivessel disease; PPCI; STEMI
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2015.09.099

Abstract Background Complete revascularization may improve outcomes compared with an infarct-related artery (IRA)-only strategy in patients being treated with primary percutaneous coronary intervention (PPCI) who have multivessel disease presenting with ST-segment elevation myocardial infarction (STEMI). However, there is concern that non-IRA PCI may cause additional non-IRA myocardial infarction (MI). Objectives This study sought to determine whether in-hospital complete revascularization was associated with increased total infarct size compared with an IRA-only strategy. Methods This multicenter prospective, randomized, open-label, blinded endpoint clinical trial evaluated STEMI patients with multivessel disease having PPCI within 12 h of symptom onset. Patients were randomized to either IRA-only PCI or complete in-hospital revascularization. Contrast-enhanced cardiovascular magnetic resonance (CMR) was performed following PPCI (median day 3) and stress CMR at 9 months. The pre-specified primary endpoint was infarct size on pre-discharge CMR. The study had 80% power to detect a 4% difference in infarct size with 100 patients per group. Results Of the 296 patients in the main trial, 205 participated in the CMR substudy, and 203 patients (98 complete revascularization and 105 IRA-only) completed the pre-discharge CMR. The groups were well-matched. Total infarct size (median, interquartile range) was similar to IRA-only revascularization: 13.5% (6.2% to 21.9%) versus complete revascularization, 12.6% (7.2% to 22.6%) of left ventricular mass, p = 0.57 (95% confidence interval for difference in geometric means 0.82 to 1.41). The complete revascularization group had an increase in non-IRA MI on the pre-discharge CMR (22 of 98 vs. 11 of 105, p = 0.02). There was no difference in total infarct size or ischemic burden between treatment groups at follow-up CMR. Conclusions Multivessel PCI in the setting of STEMI leads to a small increase in CMR-detected non-IRA MI, but total infarct size was not significantly different from an IRA-only revascularization strategy. (Complete Versus Lesion-Only Primary PCI Pilot Study [CvLPRIT]; ISRCTN70913605 )