Abstract
BackgroundThe CvLPRIT study showed a trend for improved clinical outcomes in the complete revascularisation (CR) group in those treated with an immediate, as opposed to staged in-hospital approach in patients with multivessel coronary disease undergoing primary percutaneous intervention (PPCI). We aimed to assess infarct size and left ventricular function in patients undergoing immediate compared with staged CR for multivessel disease at PPCI.MethodsThe Cardiovascular Magnetic Resonance (CMR) substudy of CvLPRIT was a multicentre, prospective, randomized, open label, blinded endpoint trial in PPCI patients with multivessel disease. These data refer to a post-hoc analysis in 93 patients randomized to the CR arm (63 immediate, 30 staged) who completed a pre-discharge CMR scan (median 2 and 4 days respectively) after PPCI. The decision to stage non-IRA revascularization was at the discretion of the treating interventional cardiologist.ResultsPatients treated with a staged approach had more visible thrombus (26/30 vs. 31/62, p = 0.001), higher SYNTAX score in the IRA (9.5, 8–16 vs. 8.0, 5.5–11, p = 0.04) and a greater incidence of no-reflow (23.3 % vs. 1.6 % p < 0.001) than those treated with immediate CR. After adjustment for confounders, staged patients had larger infarct size (19.7 % [11.7–37.6] vs. 11.6 % [6.8–18.2] of LV Mass, p = 0.012) and lower ejection fraction (42.2 ± 10 % vs. 47.4 ± 9 %, p = 0.019) compared with immediate CR.ConclusionsOf patients randomized to CR in the CMR substudy of CvLPRIT, those in whom the operator chose to stage revascularization had larger infarct size and lower ejection fraction, which persisted after adjusting for important covariates than those who underwent immediate CR. Prospective randomized trials are needed to assess whether immediate CR results in better clinical outcomes than staged CR.Trial registrationISRCTN70913605, Registered 24th February 2011.
Highlights
The Complete versus Lesion-only Primary PCI Trial (CvLPRIT) study showed a trend for improved clinical outcomes in the complete revascularisation (CR) group in those treated with an immediate, as opposed to staged in-hospital approach in patients with multivessel coronary disease undergoing primary percutaneous intervention (PPCI)
In addition we have shown that CR is not associated with an increase in total infarct size assessed by in-patient cardiovascular magnetic resonance (CMR), despite a small increase in type 4a MI compared to an infarct related artery (IRA)-only revascularization strategy [5]
Baseline characteristics Baseline characteristics and comorbidities were closely matched in the in-hospital staged and Immediate CR subgroups and were similar to those in the overall CvLPRIT study population (Table 1)
Summary
The CvLPRIT study showed a trend for improved clinical outcomes in the complete revascularisation (CR) group in those treated with an immediate, as opposed to staged in-hospital approach in patients with multivessel coronary disease undergoing primary percutaneous intervention (PPCI). Two recent randomised, controlled trials [2, 3] demonstrated reduced medium-term major adverse cardiovascular event (MACE) rates compared with infarct related artery (IRA)-only revascularization. These findings have resulted in the withdrawal of the American College of Cardiology Choosing Wisely advice of not to undertake CR at the time of PPCI [4]. In the CvLPRIT study [3], there was a trend for reduced clinical events (death/MI/heart failure) in patients who had immediate (3.1 %) rather than staged (11.9 %) CR
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