Result holds whether PCI was guided by FFR or angiography
A recent systematic review and meta-analysis demonstrates that a completer revascularization strategy as compared to culprit-lesion-only revascularization strategy results in a reduction in cardiovascular (CV) mortality. In addition, these findings were consistent when fractional flow reserve (FFR)- or angiography-guided approach were used.
These results were reported by Kevin R. Bainey, MD, MSc, of Mazankowski Alberta Heart Institute, Edmonton, Alberta, and colleagues in a manuscript published online Wednesday in JAMA Cardiology.
The recent Complete vs. Culprit-Only Revascularization to Treat Multivessel Disease After Early PCI (percutaneous coronary intervention) for STEMI (ST-segment elevation myocardial infarction) (COMPLETE) trial demonstrated that angiography-guided PCI for non-culprit with the goal of complete revascularization after STEMI showed a reduced incidence of CV death or new MI compared with PCI of the culprit lesion only.
However, the COMPLETE trial was not powered to detect reductions in CV death alone; therefore, it has been unclear whether complete revascularization reduces this hard outcome. Furthermore, it has been unclear whether a difference in CV outcomes occurs when an FFR- or an angiography-guided strategy is used for complete revascularization. The authors performed this systematic review and meta-analysis with the goal of answering these questions.
A systematic search of randomized clinical trials comparing complete revascularization versus culprit-lesion-only PCI in patient with STEMI and multivessel disease resulted in 10 studies involving 7,030 patients and a weighted mean follow-up time of 29.5 months.
The authors found that complete revascularization was associated with a significant reduction in CV death compared with culprit-lesion-only PCI (80 of 3191 [2.5%] vs. 106 of 3406 [3.1%]; odds ratio [OR], 0.69 [95% confidence interval (CI), 0.48-0.99]; p=0.05; fixed-effects model OR, 0.74 [95% CI, 0.55-0.99]; p=0.04). However, there was no difference in all-cause mortality between the two arms.
Finally, complete revascularization was associated with a reduced composite of CV death or new MI (similar to what was seen in the original COMPLETE trial), with no heterogeneity in this outcome when complete revascularization was performed using an FFR-guided strategy or an angiography-guided strategy (OR, 0.61 [95% CI, 0.38 – 0.97]; p=0.52 for interaction).
Limitations in this analysis include that individual patient data were not available for all the included studies, so medication use, left ventricular systolic function, and rate of chronic total occlusions were not fully outline in the analysis. Furthermore, limited randomized studies were available for FFR-guided multivessel PCI compared with angiographic-guided multivessel PCI, making it difficult to draw conclusions.
Despite the above limitations, these results potentially extent the benefit of a complete revascularization strategy seen in the COMPLETE trial, including a reduction in cardiovascular mortality, with that benefit being consistent in an FFR- or angiography-guided PCI approach.
Bainey KR, Engstrøm T, Smits PC, et al. Complete vs Culprit-Lesion-Only Revascularization for ST-Segment Elevation Myocardial Infarction: A Systematic Review and Meta-analysis. JAMA Cardiol 2020 May 20. https://jamanetwork.com/journals/jamacardiology/fullarticle/2766285