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BARCELONA -- If a patient is undergoing percutaneous coronary stenting for treatment of an acute myocardial infarction, researchers here suggested that all dangerous lesions in the coronary arteries should be addressed -- not just the culprit lesion.

At 12 months, 21.1% of patients who had only the culprit lesion treated experienced a major adverse cardiovascular event compared with 10% of the patient who underwent more extensive treatment of all dangerous lesions observed with angiography (P=0.009), said honorary professor of interventional cardiology at the University of Leicester and Glenfield Heart Centre in England.

In the breakdown of the components of the primary endpoint, Gershlick reported at the annual meeting of the European Society of Cardiology:

• Six people in the group that only had the culprit lesion treated died compared with two of the patients who underwent complete revascularization (P=0.14).
• Four people in the group that only had the culprit lesion treated experienced a recurrent myocardial infarction compared with two patients who had complete revascularization (P=0.39).
• Nine people in the culprit lesion group experienced heart failure compared with four patients who underwent complete revascularization (P=0.14).
• Twelve people in the culprit lesion group required revascularization compared with seven patients who underwent complete revascularization (P=0.20).

"While none of these differences were significantly significant on their own, it does show that the overall outcome was driven by hard events and not by the need for revascularization," Gershlick explained at a press conference.

Gershlick and colleagues attempted to answer the controversial question of how to manage patients being treated for an acute ST-segment elevated myocardial infarction (STEMI) who present with a culprit lesion causing the heart attack and also one or more other lesions that would be considered worrying.

Retrospective registry data and meta-analyses suggested that outcomes improved by treating non-infarct-related lesions but, he said, questions persisted about how to judge the significance of the non-infarct lesions and when to treat these lesions.

He told 番茄社区 that lesions that occluded a coronary artery by 70% or more were addressed in doing a complete revascularization. Lesions of 50% or greater occlusion were addressed if they occurred in more than one plane, he said.

"We had a median stent placement of about two in the patients where we did complete revascularization," Gershlick said.

The CvLPRIT (Complete versus Lesion-only Primary PCI Trial) was initiated in 2008, and enrolled 298 patients -- 150 underwent complete revascularization and 146 had the culprit lesion treated and then had other lesions considered at a later date.

"CvLPRIT demonstrated a 55% reduction in major adverse cardiovascular events in those patients presenting for primary percutaneous coronary interventions when the non-infarct-related artery is treated on the index admission," Gershlick said. "We saw no adverse safety signal."

The trial appears to confirm outcomes seen in the (Preventive Angioplasty in Myocardial Infarction) in which a 65% reduction in adverse events was observed if complete revascularization was performed at the time of initial percutaneous intervention.

past chair of the American College of Cardiology and Georgia and Robert Roth's Chair for Cardiac Excellence at Hoag Memorial Hospital Presbyterian, Newport Beach, Calif., told 番茄社区, "CvLPRIT is an anticipated trial coming on the heels of PRAMI. I think the interest was to see if this does make a difference. Here they looked at the two groups and found, indeed, if you do a complete revascularization at the time of the initial treatment, there is a 55% decrease in the rate of major adverse cardiovascular events.

"I think that most of us who were cautious after the PRAMI data are a little bit more excited now," she said. "Will it completely make us change? No, because the guidelines still tell us to do infarct-related angioplasty, but all of a sudden there is going to be much more interest among people in doing the other vessels that are involved at the same time."

"We think this strategy may need to be considered by future STEMI guideline committees,"Gershlick said.

"I think this is potentially a practice-changing study," professor of medicine, Harvard Medical School/Brigham & Women's Hospital, Boston, told 番茄社区. " Most interventionalists have intuitively believed that STEMI patients should undergo nonculprit percutaneous coronary intervention prior to discharge and this study supports that belief -- whether that should be during the initial procedure or the next couple of days likely depends on lesion complexity and patient comorbidities."

From the American Heart Association:

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