CvLPRIT: Treat the Infarct-Related Artery Only or All Lesions?
In patients being treated for myocardial infarction (MI), complete revascularization of all significantly blocked arteries leads to better outcomes compared to a strategy of unblocking just the "culprit" artery responsible for the heart attack, according to findings from the CvLPRIT trial presented Sept. 1 at ESC Congress 2014.
The study randomized 296 patients from seven UK interventional cardiology centers prior to undergoing primary percutaneous coronary intervention (PCI) to receive infarct-related artery (IRA)-only revascularization (n=146) or to have complete revascularization of both the IRA as well as all non-infarct related arteries (N-IRAs) (n=150) that were shown to be significantly blocked.
Results showed that one year after the procedure, patients in the complete revascularization group had significantly better outcomes compared to the IRA-only revascularization group based on a composite endpoint of major adverse cardiac events (MACE) including: all-cause mortality, recurrent MI, heart failure and ischemic-driven revascularization. MACE occurred in 21.2 percent of the IRA-only group versus 10.0 percent of the complete revascularization group (hazard ratio [HR] 0.45; p=0.009). The difference between the two groups was seen early (p=0.055 at 30 days), according to study investigators.
Investigators also noted that procedure time and contrast volume load were significantly higher in the complete revascularization group compared to the IRA-only group (55 vs. 41 mins, p< 0.0001; and 250 vs. 190 mls, p< 0.0001, respectively). However, despite these factors, complete revascularization patients had no increase in stroke, major bleeding or contrast-induced nephropathy.
According to Anthony Gershlick, MD, from University Hospitals of Leicester NHS Trust, Glenfield Hospital in Leicester, England, the CvLPRIT results reinforce the results from the PRAMI Trial, which were released last year. He noted that until now there have been conflicting data regarding the optimal management of patients undergoing primary PCI after MI who are found to have lesions in their N-IRA. He suggests these new findings strengthen arguments for complete revascularization at the time of a patient’s index hospital admissions.
"Current guidelines from ESC and American Heart Association /ACC recommend treating the IRA only, but the results of our study demonstrate a highly significant benefit with a strategy of complete revascularization instead. These findings should suggest strongly that all lesions be treated before the patient is discharged," he said.
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