Culprit or complete? Primary PCI findings add to ongoing stenting debate

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 - heart puzzle

British researchers comparing primary PCI revascularization in patients with STEMI and multivessel disease found better outcomes for patients when all lesions were treated as opposed to targeting just the culprits.

The CvLPRIT study (Complete versus Lesion-only Primary PCI trial) randomized 296 STEMI patients to either culprit lesion-only or complete revascularization. Patients were enrolled and randomized between 2011 and 2013 at seven interventional centers in the U.K. They completed follow-up in 2014.

Anthony H. Gershlick, MBBS, of Glenfield Hospital in Leicester, England, and colleagues monitored patients for a composite endpoint of all-cause death, ischemia-driven revascularization, recurrent MI or heart failure. They found major adverse cardiac events were more than doubled when patients underwent infarct-related artery revascularization as opposed to complete revascularization (21.2 percent vs 10 percent). Trends toward a benefit of complete revascularization were seen within the first 30 days following PCI, they noted.

Between the two groups, while individual parts of the composite endpoint were lower for patients with complete revascularization, they found none to be statistically significant. There were no reports of increases in stroke, major bleeding or contrast-induced nephropathy, either.

CvLPRIT follows on the heels of the recently published PRAMI (Preventative Angioplasty in Acute MI) results. However, both moderately sized studies have come to similar ends, which seem to continue the debate surrounding stenting nonculprit lesions. Other studies have suggested that focusing on severe ischemic lesions may reduce MI, death or the need for future urgent revascularization. Gershlick et al wrote that ongoing large-scale randomized trials should add clarity to the subject.

An editorial accompanying the CvLPRIT findings suggested that “(f)or now, a very reasonable approach would incorporate clinical judgment,” wrote Deepak L. Bhatt, of Brigham and Women’s Hospital Heart and Vascular Center in Boston. Bhatt offered that complete or culprit vessel revascularization may be a case-by-case basis: In some cases, like a STEMI patient with borderline cardiogenic shock, complete revascularization “may make good sense” in the initial procedure, while stable patients whose chest pain is relieved through stenting a culprit lesion “may be prudent to defer treatment of a complex left-sided bifurcation lesion until later in the hospitalization.”

The study was published in the March 17 issue of the Journal of the American College of Cardiology.