Multivessel Disease in STEMI: How COMPLETE Should We Be?

4.1 / IAGS 2019
Session 1: Coronary Session 2: STEMI
Multivessel Disease in STEMI: How COMPLETE Should We Be?
Problem Presenter:  David A. Wood, MD

 

Statement of problem or issue

Many patients with STEMI have multivessel epicardial coronary artery disease. When a STEMI patient undergoes primary PCI with successful revascularization of the culprit lesion, there is uncertainty whether other non-culprit lesions should also be treated. Further, if additional non-culprit lesions are to be treated, it is unclear whether they should be treated during the initial (index) primary PCI, later during the same hospitalization before discharge, or with a staged elective hospitalization at a later date.

Gaps in knowledge

Observational studies and meta-analyses have indicated that complete revascularization is superior to culprit-lesion-only revascularization, with a staged strategy possibly superior to a single-index-procedure strategy. However, the observed reductions were in composite endpoints only, and not in the individual hard endpoints of death or recurrent MI. Importantly, recurrent MI is difficult or impossible to ascertain in the early period after the index MI, since biomarkers are still high, and repeat revascularization as a short- or long-term endpoint event is extremely suboptimal due to foreknowledge of coronary anatomy and known benefits of medical therapies. Likewise, in studies using FFR-guided decision making for non-culprit lesion treatment, improvements occurred in composite endpoints only and not in individual hard endpoints. This finding has held even when confined to the most severe disease (3-vessel disease with ≥90% stenoses). Finally, all studies to date have been underpowered for long-term death/MI events.

Possible solutions and future directions

The COMPLETE trial (NCT01740479) has recently finished enrolling 4042 STEMI patients with multivessel disease at 150 sites in 30 countries. Patients were randomized to either staged complete revascularization (vessel diameter >2.5 mm) or culprit-vessel-only PCI. Results will be presented in August 2019 at ESC with simultaneous publication in NEJM. The COMPLETE trial should provide crucial information on the appropriate strategy for revascularization of STEMI patients with multivessel disease.