Complete versus Lesion-only PRimary PCI Trial - CvLPRIT

Dec 17, 2019
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Author/Summarized by Author:
Anthony A. Bavry, MD, MPH, FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Date Presented:
09/01/2014
Date Published:
12/16/2019
Date Updated:
12/17/2019
Original Posted Date:
03/09/2015
References

Contribution To Literature:

The CvLPRIT trial demonstrated that complete revascularization reduced adverse cardiovascular events.

Description:

The optimal management approach for multivessel coronary disease during primary percutaneous coronary intervention (PCI) remains controversial. Current guidelines recommend treating the infarct-related artery. The goal of the CvLPRIT trial was to evaluate PCI of the infarct-related artery compared with complete revascularization at the index admission among participants with ST-segment elevation myocardial infarction (STEMI).

Study Design

  • Randomized
  • Parallel
  • Stratified

Patient Populations:

Participants with STEMI, <12 hours of symptom onset

Exclusions:

  • Indication for (i.e., cardiogenic shock) or contraindication to complete revascularization
  • Previous MI
  • Prior coronary artery bypass grafting
  • Ventricular septal defect
  • Moderate to severe mitral regurgitation
  • Chronic kidney disease
  • Stent thrombosis
  • Chronic total occlusion

Primary Endpoints:

  • Mortality, MI, heart failure, and ischemia-driven revascularization at 12 months

Drug/Procedures Used:

Participants with STEMI were randomized to complete revascularization (n = 150) versus culprit vessel-only PCI (n = 146).

Principal Findings:

Overall, 296 patients were randomized. Complete revascularization was performed at the same time as the primary PCI procedure in 59%, and in a staged fashion (median 1.5 days) in 27%.

The primary outcome of mortality, MI, heart failure, or ischemia-driven revascularization at 12 months occurred in 10.0% of the complete revascularization group vs. 21.2% of the culprit-only group (p = 0.009).

  • All-cause mortality: 1.3% vs. 4.1% (p = 0.14), respectively
  • MI: 1.3% vs. 2.7% (p = 0.39), respectively
  • Heart failure: 2.7% vs. 6.2% (p = 0.14), respectively
  • Repeat revascularization: 4.7% vs. 8.2% (p = 0.2), respectively
  • Contrast-induced nephropathy: 1.4% vs. 1.4% (p = 0.95), respectively
  • Acute non–infarct-related artery infarct size (% left ventricular mass): 2.5% vs. 2.1% (p = 0.004), respectively
  • Total infarct size (% left ventricular mass): 12.6% vs. 13.5% (p = 0.57), respectively

Long-term outcomes (median of 5.6 years):

  • Mortality, MI, heart failure, or ischemia-driven revascularization: 24.0% of the complete revascularization group vs. 37.7% of the culprit-only group (p = 0.0079)
  • Mortality or MI: 10.0% of the complete revascularization group vs. 18.5% of the culprit-only group (p = 0.0175)

Interpretation:

Among patients with STEMI, complete revascularization appears beneficial at reducing major adverse cardiac events. Benefit from complete revascularization was sustained to a median follow-up of 5.6 years. This trial was not powered for individual outcomes; however, at long-term follow-up, complete revascularization was associated with a reduction in death or MI. Complete revascularization was associated with an increase in acute noninfarct artery MI; however, these were small events which were detectable by magnetic resonance imaging and did not increase total infarct size.

It is unknown if fractional flow reserve of noninfarct arteries would be beneficial in the management of these patients. A complete revascularization strategy will need to be re-evaluated in future STEMI guidelines.

References:

Gershlick AH, Banning AS, Parker E, et al. Long-Term Follow-Up of Complete Versus Lesion-Only Revascularization in STEMI and Multivessel Disease: The CvLPRIT Trial. J Am Coll Cardiol 2019;74:3083-94.

Editorial Comment: Cayla G, Lattuca B. Long-Term Outcomes on Multivessel Disease STEMI Patients: Which Is the Culprit Lesion? J Am Coll Cardiol 2019;74:3095-8.

McCann GP, Khan JN, Greenwood JP, et al. Complete Versus Lesion-Only Primary PCI: The Randomized Cardiovascular MR CvLPRIT Substudy. J Am Coll Cardiol 2015;66:2713-2724.

Gershlick AH, Khan JN, Kelly DJ, et al. Randomized Trial of Complete Versus Lesion-Only Revascularization in Patients Undergoing Primary Percutaneous Coronary Intervention for STEMI and Multivessel Disease: The CvLPRIT Trial. J Am Coll Cardiol 2015;65:963-972.

Editorial Comment: Bhatt DL. Do We Really Know the CvLPRIT in Myocardial Infarction? Or Just Stent All Lesions? J Am Coll Cardiol 2015;65:973-975.

Presented by Dr. Anthony Gershlick at the European Society of Cardiology Congress, Barcelona, Spain, September 1, 2014.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure

Keywords: Myocardial Infarction, Heart Failure, Coronary Disease, Percutaneous Coronary Intervention, ESC Congress, Myocardial Revascularization


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