Original Investigation
Randomized Trial of Complete Versus Lesion-Only Revascularization in Patients Undergoing Primary Percutaneous Coronary Intervention for STEMI and Multivessel Disease: The CvLPRIT Trial

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Abstract

Background

The optimal management of patients found to have multivessel disease while undergoing primary percutaneous coronary intervention (P-PCI) for ST-segment elevation myocardial infarction is uncertain.

Objectives

CvLPRIT (Complete versus Lesion-only Primary PCI trial) is a U.K. open-label randomized study comparing complete revascularization at index admission with treatment of the infarct-related artery (IRA) only.

Methods

After they provided verbal assent and underwent coronary angiography, 296 patients in 7 U.K. centers were randomized through an interactive voice-response program to either in-hospital complete revascularization (n = 150) or IRA-only revascularization (n = 146). Complete revascularization was performed either at the time of P-PCI or before hospital discharge. Randomization was stratified by infarct location (anterior/nonanterior) and symptom onset (≤3 h or >3 h). The primary endpoint was a composite of all-cause death, recurrent myocardial infarction (MI), heart failure, and ischemia-driven revascularization within 12 months.

Results

Patient groups were well matched for baseline clinical characteristics. The primary endpoint occurred in 10.0% of the complete revascularization group versus 21.2% in the IRA-only revascularization group (hazard ratio: 0.45; 95% confidence interval: 0.24 to 0.84; p = 0.009). A trend toward benefit was seen early after complete revascularization (p = 0.055 at 30 days). Although there was no significant reduction in death or MI, a nonsignificant reduction in all primary endpoint components was seen. There was no reduction in ischemic burden on myocardial perfusion scintigraphy or in the safety endpoints of major bleeding, contrast-induced nephropathy, or stroke between the groups.

Conclusions

In patients presenting for P-PCI with multivessel disease, index admission complete revascularization significantly lowered the rate of the composite primary endpoint at 12 months compared with treating only the IRA. In such patients, inpatient total revascularization may be considered, but larger clinical trials are required to confirm this result and specifically address whether this strategy is associated with improved survival. (Complete Versus Lesion-only Primary PCI Pilot Study [CvLPRIT]; ISRCTN70913605)

Key Words

complete revascularization
non-infarct-related lesion
primary percutaneous coronary angioplasty

Abbreviations and Acronyms

FFR
fractional flow reserve
HF
heart failure
IRA
infarct-related artery
MACE
major adverse cardiac event(s)
MI
myocardial infarction
MPS
myocardial perfusion scintigraphy
N-IRA
non–infarct-related artery
PCI
percutaneous coronary intervention
P-PCI
primary percutaneous coronary intervention
STEMI
ST-segment elevation myocardial infarction

Cited by (0)

The British Heart Foundation funded the study, with additional support from the National Institute of Health Research and the Medical Research Council for the cardiac magnetic resonance substudy. Funding organizations had no role in the conduct, analysis, or reporting of the study. Dr. Gershlick has received lecture fees and advisory board fees from Abbott Vascular, The Medicines Company, and AstraZeneca. Dr. Curzen has received research grants from St. Jude Medical, Haemonetics, and Medtronic; honoraria from St. Jude Medical, Haemonetics, Abbott Vascular, and HeartFlow; and nonfinancial support from Volcano outside of the current work. Dr. Dalby has served as a consultant for AstraZeneca, Boston Scientific, and Medtronic; and has received research grants from Abbott Vascular, Lilly DS Alliance, and Sanofi. Dr. Flather has served on advisory and speaker panels for AstraZeneca and Menarini International outside the current work. Dr. McCann has received research grants from Servier, Novartis, and Menarini International outside the current work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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