Complete revascularization in patients with STEMI and multivessel coronary artery disease may reduce cardiovascular outcomes to a larger extent in those with nonculprit lesion stenosis severity ≥60%, determined by quantitative coronary angiography (QCA), according to a study published Sept. 7 in the Journal of the American College of Cardiology.

In a subgroup analysis of the COMPLETE trial, Tej Sheth, MD, et al., determined the effect of nonculprit-lesion stenosis severity, measured by QCA, on the benefit of complete revascularization. The researchers determined the effect of complete revascularization vs. culprit-lesion-only PCI in patients with severe (≥60%) vs. moderate (<60%) QCA stenosis on the first coprimary outcome of cardiovascular death or new myocardial infarction (MI) and on the second coprimary outcome of cardiovascular death, new MI or ischemia-driven revascularization (IDR). Propensity matching was conducted to control for differences in baseline characteristics between patients with severe vs. moderate QCA stenosis.

Of the 4,041 patients in the COMPLETE trial, QCA was performed in 3,851 patients with 5,355 nonculprit lesions. Of these, 2,627 had one nonculprit lesion and 1,224 had two or more nonculprit lesions. QCA stenosis was severe in 2,479 patients and moderate in 1,372 patients. Those with severe QCA stenosis were less likely to smoke but more likely to have hypertension, dyslipidemia or elevated body mass index.

Among the 2,479 patients with severe stenosis, incidence of cardiovascular death or MI was 2.5% per year in those with complete revascularization vs. 4.2% per year in those with culprit-lesion-only PCI (hazard ratio [HR], 0.61; 95% confidence interval [CI], 0.47-0.79). In the 1,372 patients with moderate stenosis, cardiovascular death or MI was 3% per year among those with complete revascularization and 2.9% per year in those with culprit-lesion-only PCI (HR, 1.04; 95% CI: 0.72-1.50).

Regarding the second coprimary outcome of cardiovascular death, MI or IDR, in patients with severe stenosis, incidence was 2.9% per year for those receiving complete revascularization vs. 6.9% per year in those receiving culprit-lesion-only PCI (HR. 0.43; 95% CI, 0.34-0.54). In patients with moderate stenosis, the second coprimary outcome occurred at a rate of 3.3% per year for those with complete revascularization and 5.3% per year for those with culprit-lesion-only PCI (HR, 0.65; 95% CI, 0.47-0.89). For propensity matching, 1,225 patients with moderate stenosis were matched to 2,137 patients with severe stenosis. There were similar results in the matched population.

According to the researchers, the findings "provide insight" into how nonculprit-lesion stenosis severity may affect PCI in patients with STEMI and multivessel coronary artery disease. They conclude that complete revascularization may reduce major cardiovascular outcomes to a greater extent in patients with stenosis severity ≥60% vs. <60%. Additional research is needed to evaluate other methods of identifying nonculprit lesions for treatment, they note.

In an accompanying editorial comment Sanjay Kaul, MD, writes that the results "highlight some of the major caveats that challenge interpretation of subgroup analyses" and should be used "for informing future research" rather than "to guide clinical practice."

Clinical Topics: Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Stable Ischemic Heart Disease, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Hypertension, Chronic Angina

Keywords: Coronary Artery Disease, ST Elevation Myocardial Infarction, Coronary Angiography, Percutaneous Coronary Intervention, Body Mass Index, Myocardial Infarction, Hypertension, Dyslipidemias

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