4.1 COMPLETE Revascularization Following STEMI: Not Whether, When

These proceedings summarize the educational activity of the 16th Biennial Meeting of the International Andreas Gruentzig Society held January 31-February 3, 2022 in Punta Cana, Dominican Republic

Faculty Disclosures     Vendor Acknowledgments

2022 IAGS Summary Document

Statement of the problem or issue

Patients presenting with ST–segment-elevation myocardial infarction (STEMI) often have multivessel coronary artery disease. The large multicenter randomized COMPLETE trial enrolled patients with STEMI who underwent culprit-lesion PCI, and had at least 1 additional angiographically significant nonculprit lesion (≥70% diameter stenosis by visual estimation in a vessel with diameter of ≥2.5 mm).¹ Staged nonculprit lesion PCI with the goal of complete revascularization, which was achieved in >90% of patients, resulted in significant reductions of the individual primary outcomes of cardiovascular (CV) death, or new MI, as well as in the composite outcome of CV death, new MI, or ischemia-driven revascularization (IDR), when compared with culprit–lesion-only PCI. (8.9% vs 16.7%; P<.001 for the composite outcome). Current guidelines now recommend routine revascularization for nonculprit lesions in patients presenting with STEMI. In the COMPLETE study, nonculprit revascularization could be performed either during index hospitalization or within several weeks after discharge. A COMPLETE trial substudy demonstrated that staged nonculprit lesion PCI performed either early, that is, during the index hospitalization, or alternatively several weeks after discharge, led to a similar reduction in the composite outcome of CV death or MI, compared with culprit–lesion-only PCI.² The benefit of nonculprit-lesion PCI emerges mainly over the long term, generally years.²

Gaps in knowledge

While it has been shown that revascularization of nonculprit lesions in STEMI patients with multivessel disease is beneficial, it is unknown exactly which patients and w­hich nonculprit lesions benefit most from inpatient revascularization during the index ­hospitalization.

Possible solutions and future directions

Further studies are needed to establish how long non-culprit lesion revascularization can be safely delayed after an index STEMI presentation, while still yielding long-term clinical benefit. Understanding which factors favor inpatient complete revascularization compared to later revascularization will also be of great importance.

References

1. Mehta SR, Wood DA, Storey RF, et al. Complete revascularization with multivessel PCI for myocardial infarction. N Engl J Med. 2019;381(25):1411-1421. doi:10.1056/NEJMoa1907775

2. Wood D, Cairns J, Wang J, et al. Timing of staged nonculprit artery revascularization in patients with ST-segment elevation myocardial infarction. J Am Coll Cardiol. 2019;74(22):2713-2723. doi:10.1016/j.jacc.2019.09.051