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Question clinique
For patients with ST-elevation myocardial infarction, does complete revascularization of all culprit and nonculprit lesions lead to better long-term outcomes?
L’Essentiel
Revascularization of both culprit and nonculprit lesions following ST-elevation myocardial infarction (STEMI) results in fewer recurrent myocardial infarctions (MIs). You would need to treat 40 people with complete revascularization to prevent 1 new MI over a period of 3 years. 1b
Référence
Plan de l'etude: Randomized controlled trial (nonblinded)
Financement: Industry + govt
Cadre: Inpatient (any location)
Sommaire
This study enrolled patients presenting with STEMI who had successful culprit-lesion percutaneous coronary intervention (PCI) and at least one additional angiographically significant nonculprit lesion that was amenable to PCI. Using concealed allocation, the investigators randomized these patients to receive either complete revascularization of all suitable nonculprit lesions (n = 2016) or culprit-lesion PCI only (n = 2025). Complete revascularization could occur at the index hospitalization or within 45 days of randomization. Both study groups also received guideline-based medical therapy. Baseline characteristics were similar in the 2 groups. For the primary outcome of death from cardiovascular causes or new MI at a median follow-up of 3 years, the complete revascularization group fared better than the culprit-lesion only group (7.8% vs 10.5%; HR 0.74; 95% CI 0.60 - 0.91; P = .004). This was due to fewer MIs in the the complete revascularization group (5.4% vs 7.9%; HR 0.68; 0.53 - 0.86). The complete revascularization group also had a decreased rate of ischemia-driven revascularization (1.4% vs 7.9%; HR 0.18; 0.12 - 0.26) and unstable angina (1.2% vs. 2.2%; HR 0.53; 0.40 - 0.71). There were no significant differences in the 2 groups in the risks of major bleeding, stroke, or stent thrombosis
Reviewer
Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL