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Complete Revascularization in ST-Elevation Myocardial Infarction?

New England Journal of Medicine, Ahead of Print. <br/>
Editor's Note: The narration and closed captions in this video are in English. For subtitles in 13 other languages, see this video on the website of the World Health Organization.

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Editorial

Lars Køber, M.D.

March 18, 2017DOI: 10.1056/NEJMe1702825

Article

Between 40 and 50% of patients who present with acute ST-elevation myocardial infarction (STEMI) have multivessel coronary artery disease.1,2 Joint guidelines from the American College of Cardiology, the American Heart Association, and the European Society of Cardiology recommend treatment of the culprit vessel only, but data from a few trials of intermediate size favor complete revascularization, mainly on the basis of reductions in the need for repeat revascularizations.3-7 The severity of nonculprit vessel lesions has generally been assessed by means of angiography; in one trial, fractional flow reserve (FFR) was used.7 Important questions therefore remain: among patients presenting with STEMI, which ones should be offered complete revascularization, when should the procedure be performed, and what measure should be used to determine the significance of the lesions?

Smits and colleagues now report in the Journal the results of a large randomized trial in which the use of FFR-guided complete revascularization was compared with treatment of the culprit vessel only among patients presenting with STEMI.8 A total of 885 patients with stenosis of at least 50% of the diameter of a nonculprit vessel were randomly assigned in a 1:2 ratio to undergo FFR-guided revascularization of non–infarct-related coronary arteries or treatment of the infarct-related artery only. FFR measurements were performed in both groups (successfully in 97% of patients), but patients in the infarct-artery-only group and their treating physicians were not informed of the results, although they were informed of the results of angiography. FFR-guided complete revascularization was performed in more than 80% of patients assigned to that group (all within 3 days) during the index procedure; in the infarct-artery-only group, 10% of patients had a planned revascularization within the first 45 days after the index procedure (not included in the primary end point). The primary composite outcome (death, nonfatal myocardial infarction, revascularization, and cerebrovascular events) was two thirds lower in the complete-revascularization group than in the infarct-artery-only group, an outcome driven mainly by a reduction in any revascularization. The percentage of patients having nonfatal myocardial infarction appeared to be lower in the complete-revascularization group than in the infarct-artery-only group, but the numbers of these events were relatively small and there was no significant difference between groups. Mortality was low and was similar in the two groups (1.4% and 1.7%, respectively, at 12 months). In both groups, only half the patients with an angiographic nonculprit stenosis had a significant stenosis according to FFR measurement and thus underwent revascularization subsequently in the complete revascularization group.

Among patients undergoing complete revascularization, the procedure added an average of only 6 minutes to the total time required. FFR measurement was feasible in the acute stage (during the primary percutaneous coronary intervention). Rates of adverse events were low immediately after the index procedure in both groups, which supports the proposition that FFR and revascularization can be safely performed simultaneously, making it possible for patients to avoid additional catheterization procedures. However, patients included in trials are often at lower risk than those who are not included, and it is uncertain whether these results can be extrapolated to sicker patients, who may be at greater risk for complications associated with a prolonging of the index procedure but may also receive greater benefit with respect to later cardiovascular events.

Should the Compare-Acute trial, in combination with previous randomized trials, result in a change in guidelines to support the use of complete revascularization in all patients with STEMI and multivessel disease? This strategy appears to be safe, but it may not be necessary in all patients. Only one third of repeat revascularizations were performed as a result of acute coronary syndromes, a finding that is consistent with that in another trial involving FFR-guided intervention.7 The results of the Compare-Acute trial represent a select population in which fewer than one patient per month per center underwent randomization, on average. Unfortunately, the investigators were not able to provide information on patients who were eligible for the study but were not enrolled. In addition, treatment allocation and angiographic results were known by treating physicians. The observation that patients with FFR-negative nonculprit stenoses in the complete-revascularization group had fewer events than patients with FFR-negative nonculprit stenoses in the infarct-artery-only group suggests that knowledge that the patient had not undergone complete revascularization may have triggered earlier repeat revascularization in the infarct-artery-only group. It remains uncertain whether the strategy will translate into a reduction in the rate of hard end points. In one trial involving complete upfront revascularization that reported a reduction in a hard end point (death from cardiac causes or nonfatal myocardial infarction), annual mortality was similar to that among patients in the current study, but the patients were followed for a longer period of time; that trial did not include measurement of FFR.5 Longer-term follow-up is also planned in the current study.

When considered together with previously published data, the report by Smits and colleagues indicates that a strategy of FFR-guided complete revascularization results in lower rates of major adverse cardiovascular events and of revascularization procedures performed than a strategy based only on angiography. However, the cardiovascular benefit was driven largely by revascularization. Larger trials powered for hard end points (recurrent myocardial infarction or cardiovascular mortality) are needed to determine the effects of an FFR-guided complete-revascularization strategy on these outcomes and to identify the subgroups of patients most likely to benefit (recruitment is ongoing in one trial of 3900 patients [ClinicalTrials.gov number, NCT01740479]).

Disclosure forms provided by the author are available with the full text of this editorial at NEJM.org.

This editorial was published on March 18, 2017, at NEJM.org.

Source Information

From the Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen.

References

References

  1. 1

    Kelbaek H, Terkelsen CJ, Helqvist S, et al. Randomized comparison of distal protection versus conventional treatment in primary percutaneous coronary intervention: the Drug Elution and Distal Protection in ST-Elevation Myocardial Infarction (DEDICATION) trial. J Am Coll Cardiol 2008;51:899-905
    CrossRef | Web of Science | Medline

  2. 2

    Rasoul S, Ottervanger JP, de Boer MJ, et al. Predictors of 30-day and 1-year mortality after primary percutaneous coronary intervention for ST-elevation myocardial infarction. Coron Artery Dis 2009;20:415-421
    CrossRef | Web of Science | Medline

  3. 3

    Kolh P, Windecker S. ESC/EACTS myocardial revascularization guidelines 2014. Eur Heart J 2014;35:3235-3236
    Web of Science | Medline

  4. 4

    O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013;127:529-555
    CrossRef | Web of Science | Medline

  5. 5

    Wald DS, Morris JK, Wald NJ, et al. Randomized trial of preventive angioplasty in myocardial infarction. N Engl J Med 2013;369:1115-1123
    Free Full Text | Web of Science | Medline

  6. 6

    Gershlick AH, Khan JN, Kelly DJ, et al. Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel disease: the CvLPRIT trial. J Am Coll Cardiol 2015;65:963-972
    CrossRef | Web of Science | Medline

  7. 7

    Engstrøm T, Kelbæk H, Helqvist S, et al. Complete revascularisation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multivessel disease (DANAMI-3–PRIMULTI): an open-label, randomised controlled trial. Lancet 2015;386:665-671
    CrossRef | Web of Science | Medline

  8. 8

    Smits PC, Abdel-Wahab M, Neumann F-J, et al. Fractional flow reserve–guided multivessel angioplasty in myocardial infarction. N Engl J Med. DOI: 10.1056/NEJMoa1701067
    CrossRef

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