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FRAME OF REFERENCE
Complete Immediate Revascularization of the
Patient With ST-SegmentElevation Myocardial
Infarction Is the New Standard of Care
A
pproximately half of patients with ST-segmentelevation myocardial infarction
(STEMI) have angiographically significant multivessel disease and, in these pa-
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planned recruitment of 629 patients was completed and reversible ischemia. It is true that the subsequent man-
the observed relative risk reduction in favor of complete agement of the patients in these trials did not include
revascularization was 44% (P=0.004), although this was protocol-mandated ischemia testing, but their care was
exclusively driven by a reduction in the need for isch- in the hands of experienced cardiologists who could and
emia-driven revascularization, with no effect on mortality did manage these patients as they saw fit. Because none
or MI.3 of these trials was fully blinded, the clinicians knew which
patients had angiographically significant but untreated
lesions, and if they felt there was a need for ischemia
SUMMARY testing or further revascularization, then it was per-
These 3 trials provide sufficient grounds to support im- formed. In any event, this criticism is based on the as-
mediate complete revascularization as the new standard sumption that at least 1 mechanism of benefit in these
of care for patients with STEMI and multivessel disease trials was relief of ischemia in the territory of nonculprit
who do not have left main coronary artery disease or arteries. However, in a 200-patient substudy of CvLPRIT
cardiogenic shock, or in whom the only nonculprit lesion using cardiovascular MRI, there was no evidence of a
is a chronic total occlusion. Why, then, have the most difference in ischemic burden at follow-up.4 This is an
recent European and US guidelines only given this treat- important observation, because it may also explain, in
ment strategy a lukewarm class IIb recommendation? part, the results of DANAMI-3 PRIMULTI. In this trial, un-
Even in my own center, where we do >700 primary PCI like PRAMI and CvLPRIT, fractional flow reserve decision
procedures per year, there is limited enthusiasm for im- making was used to select which nonculprit stenoses
mediate complete revascularization. should be stented within the diameter stenosis range of
50% to 90%. This resulted in approximately one-third of
lesions (31%) that would have been stented on standard
Resistance to Change angiographic criteria being left untreated because of
I frequently hear cardiologists saying that the outcomes fractional flow reserve values >0.80. It should be noted
in these trials do not reflect what they see in their dai- that this study failed to show any effect on mortality or
ly practice. In other words, my anecdotal experience nonfatal MI. However, if in fact a major mechanism of
trumps the randomized trials results. This is not evi- benefit is stabilization of nonculprit but nevertheless vul-
dence-based medicine. nerable plaques, then angiographic selection criteria (as
used in PRAMI and CvLPRIT) may be superior to fraction-
al flow reserve guidance in this setting (ongoing studies
Undertreatment in the Culprit-Only Groups will hopefully clarify this point).
I also frequently hear the criticism that the control
groups in all 3 trials were undertreated. Cardiologists
state that the patients randomly assigned to culprit-only Staging
PCI should all have undergone ischemia testing and then Many cardiologists are convinced of the need for com-
been revascularized if there was evidence of important plete revascularization in patients with STEMI and mul-
FRAME OF REFERENCE
tivessel disease, but prefer to undertake staged rath- good result in the culprit artery, and it is technically and
er than immediate nonculprit PCI. Often, this choice logistically feasible.
is driven not by evidence but by local reimbursement
practices, a questionable motive for potentially compro-
mising care. Staging is clinically and economically inef- DISCLOSURES
ficient and exposes patients to a variety of avoidable None.
risks, including further vascular access, guide catheter
manipulation, contrast exposure, and administration of
potent antithrombotic drugs. Therefore, in an overall AFFILIATION
health economic analysis, the immediate complete re- From West of Scotland Regional Heart and Lung Centre, Golden
vascularization strategy will always win over a staged Jubilee National Hospital, Glasgow, Scotland, UK.
approach, even when the staging occurs during the
index procedure. One can speculate that the strategy
used in DANAMI-3 PRIMULTI of staging all nonculprit PCI FOOTNOTES
procedures, albeit within the index admission, may have Circulation is available at http://circ.ahajournals.org.
diluted the treatment effect. Staging beyond the index
admission seems particularly unattractive given the ear-
ly separation of the event curves in all 3 trials. Of course, REFERENCES
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The operators in these trials were all experienced inter- sus lesion-only revascularization in patients undergoing primary
ventional cardiologists. Nevertheless, as can be seen percutaneous coronary intervention for STEMI and multivessel
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Complete revascularisation versus treatment of the culprit lesion
amenable to noncomplex PCI. only in patients with ST-segment elevation myocardial infarction
and multivessel disease (DANAMI-3PRIMULTI): an open-label,
randomised controlled trial. Lancet. 2015;386:665671.
Conclusions 4. McCann GP, Khan JN, Greenwood JP, Nazir S, Dalby M, Curzen N,
Hundreds of patients consented to participate in these Hetherington S, Kelly DJ, Blackman DJ, Ring A, Peebles C, Wong
J, Sasikaran T, Flather M, Swanton H, Gershlick AH. Complete
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we owe it to these patients to adopt the strategy of im- CvLPRIT substudy. J Am Coll Cardiol. 2015;66:27132724. doi:
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Circulation. 2017;135:1571-1573
doi: 10.1161/CIRCULATIONAHA.117.025265
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