COMPLETE revascularization bests culprit only PCI at reducing death risk and MI recurrence: ESC 2019 Update

COMPLETE revascularization bests culprit only Percutaneous Coronary Intervention (PCI) at reducing death risk and MI recurrence is a new ESC 2019 Update.

Opening all the clogged arteries with stents could significantly reduce the risk of cardiovascular death or myocardial infarction (heart attack) in patients with ST-elevation myocardial infarctions as compared to opening only the single clogged artery that caused the heart attack.

This is the finding of COMPLETE (the Complete versus Culprit-Only Revascularization Strategies to Treat Multivessel Disease after Early PCI for STEMI) trial presented at the annual congress of the European Society of Cardiology (ESC) held together with the World Congress of Cardiology in Paris, France. The study is the first large, randomized, international trial to show a reduction in major outcomes with this approach.

According to the study, published in the New England Journal of Medicine, revascularization of more than just the culprit lesion in patients with ST-elevation myocardial infarctions (STEMI) could significantly reduce their risk of cardiovascular death or heart attack.

About half of the victims of a heart attack have additional clogged arteries in addition to the one that caused the heart attack. Previously, the treatment focused on opening the one artery that caused heart attack, and other blockages were left for treatment with medication alone.

The new study, a collaboration of 130 hospitals in 31 countries, has shown that opening all the blockages is rather than opening only the one blockage causing the heart attack led to a 26 per cent reduction in the patient's risk of dying or having a recurrent heart attack.

"Given its large size, international scope and focus on patient-centred outcomes, the COMPLETE trial will change how doctors treat this condition and prevent many thousands of recurrent heart attacks globally every year," said study leader Dr. Shamir R. Mehta of the Population Health Research Institute (PHRI) of McMaster University and Hamilton Health Sciences.

He said that although it had been known that opening of the single blocked artery that caused the heart attack with stents was beneficial, it was unclear whether additional stents to clear the other clogged arteries further prevented death or heart attack. In most cases, doctors would just treat the additional blockages with medication alone.

"This study clearly showed that there is long term benefit in preventing serious heart-related events by clearing all of the arteries. There was also no major downside to the additional procedures," said Mehta.

The study involved 4,041 patients s who had experienced an ST-elevation myocardial infarction (STEMI), who had multi-vessel coronary artery disease, and who had undergone successful percutaneous coronary intervention of the culprit lesion.

Participants were randomized either to complete revascularization of all angiographically significant nonculprit lesions, or to no further revascularization, and were followed for a median of 3 years.

Key findings include:

• Of the patients who underwent complete revascularization, 7.8% experienced either cardiovascular death or another myocardial infarction, compared with 10.5% of those who only had revascularization of the culprit lesion, representing a significant 26% reduction in the incidence of this composite coprimary outcome


• The decrease in events was driven by a significant 32% reduction in the incidence of new myocardial infarction – particularly non-STEMI, new STEMI, and myocardial infarction type 1 – in the complete revascularization group, with only a 7% reduction in the incidence of death from cardiovascular causes.


• With the second coprimary outcome of a composite of cardiovascular death, myocardial infarction, or ischemia-driven revascularization, this was seen in 8.9% of patients in the complete revascularization group compared with 16.7% of patients with the culprit-lesion-only group; a significant 49% reduction in incidence.


• 37 complete revascularizations would need to be performed to prevent one incidence of cardiovascular death or myocardial infarction.


• To prevent cardiovascular death, myocardial infarction, or ischemia-driven revascularization, the number needed to treat was 13.


• The timing of complete revascularization did not appear to affect the benefits of the procedure, which were consistent among patients who underwent complete revascularization during their index hospitalization and in those who underwent the procedure after hospital discharge.


• The study also did not find any significant differences between the two groups in the risks of major bleeding, stroke, or stent thrombosis.


• The complete revascularization group did experience a nonsignificant 59% higher odds of contrast-associated acute kidney injury, which was attributed to the nonculprit lesion revascularization in seven patients in the complete revascularization group.

The bottom line of the study is --> Opening all clogged arteries with stents after a serious heart attack is much better than opening only the single clogged artery that caused the heart attack.

To read the complete study log on to DOI: 10.1056/NEJMoa1907775