Culprit Only vs. Multivessel Intervention in STEMI: Targets, Guidance, Data Review, and Future Directions

Educational Objectives

Describe the role of staged percutaneous coronary intervention in the management of patients with ST-elevation myocardial infarction who have multivessel disease.

Summary

• Percutaneous coronary intervention (PCI) is effective in reducing angina and subsequent revascularization. This is true in patients with and without acute coronary syndrome, including patients with ST-elevation myocardial infarction (STEMI) who have multivessel disease.
• Current evidence is encouraging (encouraging enough to lead to a change in the guidelines to permit non-culprit lesion PCI), but insufficient to determine whether non-culprit lesion PCI reliably reduces death or MI.
• The COMPLETE trial, which is underway, is powered to detect differences in death or MI and designed to determine whether staged PCI reliably reduces these events in patients with STEMI and multivessel disease.

Approximately half of patients with ST-elevation myocardial infarction (STEMI) have multivessel disease. Options for these patients include: 1) culprit artery-only primary percutaneous coronary intervention (PCI), with PCI of non-culprit arteries limited to spontaneous ischemia or intermediate- or high-risk findings on predischarge noninvasive testing (otherwise known as the previous guidelines); 2) multivessel PCI at the time of primary PCI (an option in recently updated guideline); or 3) culprit artery-only primary PCI followed by staged PCI of non-culprit arteries. Given that a staged approach hasn’t been a popular choice for clinician or patient, the first 2 options seem to rule.

There is evidence that a preventive PCI approach might be beneficial (PRAMI, CvLPRIT, DANAMI-3-PRIMULTI, and PRAGUE-13), but critics contend that the problem, for the most part, was that seriously flawed study designs prevented meaningful conclusions regarding optimal treatment. The problem: Patients who received only PCI of the culprit lesion were not allowed to be treated according to the current guideline recommendations.

While questions remain, there was enough evidence to permit the PCI guidelines writing committee to recently update the recommendations, upgrading multivessel primary PCI in hemodynamically stable patients with STEMI from Class III (harm) to a Class IIb recommendation. The writing committee did not endorse routine PCI of non-culprit lesions but instead supported it as an option for patients, based on clinical data, lesion severity/complexity, and risk of contrast nephropathy.¹

So, this approach can be considered based on “the indications for and timing of multivessel PCI,” with physicians integrating “clinical data, lesion severity/complexity, and risk of contrast nephropathy to determine the optimal strategy.¹”

The guidelines committee also noted: “Although several observational studies and a network meta-analysis have suggested that multivessel staged PCI may be associated with better outcome than multivessel primary PCI, there are insufficient observational data and no randomized data at this time to inform a recommendation with regard to the optimal timing of nonculprit vessel PCI.” Thus, some kind of “staged” approach is still an option, but there is no final answer as to whether this approach can be harmful.

What about high-risk patients in general? At the 2016 meeting of the European Society of Cardiology, Jean-Philippe Collet, MD, PhD, from the Institut de Cardiologie Hôpital Pitié-Salpetrière (Paris, France), presented the results of the Active Detection and Management of the Extension of Atherothrombosis in High Risk Coronary Patients in Comparison with Standard of Care for Coronary Atherosclerosis (AMERICA) study.

Patients were randomized to a proactive prevention program including revascularization of asymptomatic multisite artery disease when appropriate, lifestyle changes, and an aggressive pharmacological approach (n = 263), or to a more conventional strategy based on treatment of coronary artery disease and only symptomatic extra-coronary lesions (n = 258). High risk was defined as either recently diagnosed 3-vessel disease (within the past 6 months) or acute coronary syndrome in the past month (in patients ≥75 years old).

The results: detecting and treating the asymptomatic sites of stenosis did not improve 2-year outcomes compared to a more traditional approach of managing only symptomatic lesions.

The COMPLETE Answer

Shamir R. Mehta, MD, is a professor at McMaster University, Hamilton, ON, Canada, and Director, Interventional Cardiology, Hamilton Health Sciences. He recently noted that there is a global trial underway, with ≈2,000 patients enrolled in 136 centers as of the end of 2016.

Patients are being randomized to staged non-culprit lesion PCI plus optimal medical therapy or optimal medical therapy alone (with an expected 1,950 patients per arm). The trial has some interesting features, including:

• Powered to detect reductions in cardiovascular death or MI
• High proportion of dual antiplatelet therapy with aspirin plus ticagrelor
• Very high proportion of drug-eluting stent use
• Angiographic core laboratory (100% of all angiograms)
• Non-culprit lesion substudy using optical coherence tomography
• Chronic total occlusion, non-culprit lesion substudy
• Coronary artery bypass graft surgery registry

Readings

1. Levine GN, Bates ER, Blankenship JC, et al. 2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. J Am Coll Cardiol 2016;67:1235-50. http://content.onlinejacc.org/article.aspx?articleID=2463473

Disclosures

Shamir R. Mehta, MD, FACC
This author has nothing to disclose.

Interviewer: Alfred A. Bove, MD, PhD, MACC
World HealthNetworks, Inc (C); Merck & Co Inc (G); Insight Telehealth Systems Inc (C,E)

The planning committee reported nothing to disclose.

A = Advisory panel B = Speakers’ bureau C = Consultant fees/honoraria D = Data and Safety Monitoring Board E = Equity interests/stock options F = Fellowship support G = Grant support L = Licensing Agreement O = Other relationship R = Royalties S = Salary W = Expert witness

Acknowledgements

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

AC481102

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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