Long-term follow-up of complete versus lesion-only revascularization in STEMI and multivessel disease

Selected in JACC by N. Ryan , D. Milasinovic

The CvLPRIT trial demonstrated that at one-year MACE (all-cause death, recurrent MI, heart failure and ischaemia driven revascularisation) was significantly lower in the CR group compared to the IRA group with no differences in safety endpoints. In this paper, the authors report the extended follow-up to a median of 5.6 years.

Reviewers

Nicola Ryan

@NicolaRyanI1

Interventional cardiologist / Cardiologist

Aberdeen Royal Infirmary - Aberdeen, United Kingdom

Dejan Milasinovic

@MilasinD18

Interventional cardiologist / Cardiologist

Clinical Centre of Serbia - Belgrade, Serbia

Our Comment

This joint review is part of the PCRonline GLOBAL Journal Club Initiative by selected members of the EAPCI/PCR Journal Club and PCR NextGen, and is based on the underlying idea of “Bringing peers together, exchanging ideas, towards a common standard of care”.

CvLPRIT was a randomised control trial comparing angiography guided complete revascularisation (CR), during inpatient admission, to infarct-related artery revascularisation (IRA) alone in 296 patients presenting with STEMI.

Why this study – the rationale/objective?

Multivessel disease (MVD) is commonly found in patients presenting with STEMI, the optimal treatment of which is an ongoing topic of debate.

The CvLPRIT trial demonstrated that at one-year MACE (all-cause death, recurrent MI, heart failure and ischaemia driven revascularisation) was significantly lower in the CR group compared to the IRA group (10.0% vs. 21.2%, HR 0.45; 95% CI 0.24-0.84; p=0.009) with no differences in safety endpoints. In this paper, the authors report the extended follow-up to a median of 5.6 years (range 0-7.3. years).

How was it executed – the methodology?

CvLPRIT was a randomised control trial in patients with MVD undergoing PPCI for STEMI. Patients were randomised, stratified for location (anterior/non-anterior) and symptom onset (≤3hours/>3hours) in a 1:1 fashion to CR or IRA. Data was retrospectively collected from the end of 12 months follow up (May 2012-May 2014) until August 2018.

• The primary endpoint was MACE (all-cause death, recurrent MI, heart failure and ischaemia driven revascularisation (IDR))
• Secondary endpoints were the composite of death/MI and the individual components of MACE
• Landmark analysis of MACE events from 12 months to follow-up was carried out.

What is the main result?

CvLPRIT randomised 296 patients, 150 to the CR arm and 146 to IRA, long-term data was available for 91.8% and 92% of patients respectively.

• At a median of 5.6 years, MACE was significantly lower in the CR group compared to the IRA group (24.0% vs. 27.7%; HR 0.57; 95%CI 0.37-0.87; p= 0.0079).
• The composite of death and MI was also lower in the CR group (10.0% vs. 18.5%; HR 0.47; 95%CI 0.25-0.89; p = 0.0175) at long-term follow-up.
• There were no differences between groups in the individual components of MACE including IDR (11.3% (CR) vs 13.0% (IRA); HR 0.76; 95%CI 0.4-1.49; p = 0.4447).
• From 12 months to the end of follow-up, MACE was numerically but not statistically lower in the CR group (17.1% vs. 23.3%; HR 0.72, 95%CI 0.40-1.27; p=0.248), with a trend towards reductions in the composite endpoint of death and MI (8.9% vs. 16.5%; HR 0.53 (0.25-1.12); p= 0.0905).

Critical reading and relevance for clinical practice

The results of this study show that a CR strategy remains superior to an IRA strategy at long term follow-up in patients with MVD undergoing PPCI for STEMI. The initial benefit in reducing MACE is sustained, with a trend towards further reduction in the composite rate of death and MI in the CR group after 12 months follow-up. Importantly, at long-term follow-up the hard endpoint of death and MI was significantly lower in the CR group, although there were no differences in the individual components of MACE between groups. This data complements the recently published COMPLETE trial which showed a significant reduction in cardiovascular death or MI at a median of 3 years, when STEMI patients with MVD were treated with complete as opposed to culprit lesion-only revascularisation.

A note of caution when interpreting the results, long-term data was collected in a retrospective fashion with no core lab review or adjudication of events. Furthermore, the numbers included in the trial were relatively small, and as with all trials one must bear in mind that the results may not be generalisable to groups not included in the trial such as the very elderly or frail patient.

In summary CvLPRIT provides additional long-term randomised control data showing the benefit of CR in STEMI. Given the fact that in the COMPLETE trial decision-making was based purely on angiography (FFR of non-culprit lesions was measured in only 1% of patients), the clinical impact of the selection of non-infarct lesions, angiography versus physiology guided, remains open to debate. The ongoing FLOWER-MI trial will further enhance the evidence in this area.