Arq. Bras. Cardiol. 2020; 115(2): 238-240
Is Complete Revascularization Truly Superior to Culprit-Lesion-Only PCI in Patients Presenting with ST-segment Elevation Myocardial Infarction?
Christina Grüne de Souza e Silva
This Short Editorial is referred by the Research article "Complete Revascularization Versus Treatment of the Culprit Artery Only in ST Elevation Myocardial Infarction: A Multicenter Registry".
Primary percutaneous coronary intervention (PCI) is a standard therapy for patients with acute ST-segment elevation myocardial infarction (STEMI), and its goal is to restore blood flow to the coronary artery that is judged to be causing the myocardial infarction (known as the culprit artery). In up to half of such patients, major stenoses in one or more coronary arteries that are not responsible for the myocardial infarction (nonculprit lesions) may also be seen during the index angiography. Since patients with acute STEMI and multivessel coronary artery disease (CAD) have worse clinical outcomes compared with patients with single-vessel disease, it has been questioned if PCI treatment of all significant nonculprit lesions following primary PCI (complete revascularization) could improve prognosis.
A number of randomized clinical trials (RCT) have addressed this topic by comparing outcomes of patients with STEMI and multivessel CAD who underwent complete revascularization versus treatment of the culprit-lesion-only PCI (incomplete revascularization). Previously, intermediate-sized RCT – have shown that complete revascularization is safe and reduces the risk of composite outcomes, with results driven predominantly by the decreased risk of subsequent revascularization. Recently, the COMPLETE (Complete versus Culprit-Only Revascularization Strategies to Treat Multivessel Disease after Early Percutaneous Coronary Intervention [PCI] for STEMI) trial, a larger RCT, showed that the risk of the composite outcome death from cardiovascular causes or recurrent myocardial infarction was lower in the complete revascularization group than in the culprit-lesion-only PCI group in patients presenting with STEMI, this benefit been driven by a reduction in new myocardial infarction. Moreover, in the largest meta-analysis of RCT performed to date addressing this topic, complete revascularization was associated with a reduction in cardiovascular mortality compared with culprit-lesion-only PCI in patients with STEMI and multivessel CAD without cardiogenic shock at presentation (odds ratio, 0.69; 95% confidence interval [CI], 0.48-0.99; p=0.05).
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