Complete revascularization appears to be optimal for heart attack patients

by Bruce Sylvester – Following heart attack, patients who undergo revascularization of all significantly blocked arteries achieve better outcomes than patients who undergo revascularization of the “culprit” artery only,  researchers  reported on Sept. 1, 2014 at the European Society of Cardiology Congress 2014.
Findings from “Complete versus Lesion only PRimary-PCI Trial” (CvLPRIT), were presented by  investigator Anthony Gershlick, MD, from University Hospitals of Leicester NHS Trust, Glenfield Hospital, in Leicester, UK.

“Until now there have been conflicting data regarding the optimal management of patients who, whilst undergoing primary percutaneous coronary intervention (P-PCI) after myocardial infarction (MI) are also found to have lesions in their non-infarct related artery (N-IRA),” said Dr. Gershlick.“Current guidelines from ESC and AHA /ACC recommend treating the infarct-related artery (IRA) only, but the results of our study demonstrate a highly significant benefit with a strategy of complete revascularization instead. These findings should suggest strongly that all lesions be treated before the patient is discharged,” he added.

CvLPRIT researchers enrolled 296 heart attack patients at seven UK interventional cardiology centers. Before undergoing P-PCI the investigators randomized the subjects to receive IRA-only revascularization (n=146) or revascularization of the IRA and all N-IRAs (n=150) deemed to be significantly blocked.

Among complete revascularization subjects, physicians treated the IRA first, then the N-IRAs, always during the same index hospital admission.

The researchers reported that at one year after intervention, subjects in the complete revascularization group had achieved significantly better outcomes than subjects who had only the IRA revascularized.

This finding was based on a composite endpoint of major adverse cardiac events (MACE) including: all-cause mortality, recurrent MI, heart failure and ischemic-driven revascularization. MACE appeared in 21.2% of the IRA-only arm versus 10.0% of the complete revascularization group (hazard ratio [HR] 0.45; p=0.009).
Procedure time and contrast volume load were significantly higher in the complete revascularization cohort compared to the IRA-only cohort (55 vs. 41 mins, p< 0.0001; and 250 vs. 190 mls, p< 0.0001, respectively). However, the complete revascularization patients showed no relative increase in stroke, major bleeding or contrast-induced nephropathy.

The CvLPRIT results correlate strongly with those of the earlier “Preventive Angioplasty in Myocardial Infarction” (PRAMI) Trial, presented last year at the European Society of Cardiology congress.

“The PRAMI trial reported clear clinical benefit in treating both IRA and N-IRAs at the index P-PCI, but there was some criticism of the trial design,” said Dr. Gershlick. “As a result, PRAMI has not led to widespread changes in clinical practice, with IRA-only revascularization at P-PCI remaining by far the more common practice.”

Dr. Gershlick added that the CvLPRIT findings reinforce the PRAMI-based argument for a strategy of complete revascularization at the time of index hospital admission. “The early separation of the curves in CvLPRIT suggests a delayed staged out-patient complete strategy may not be as effective,” he said