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BARCELONA -- Results of the CvLPRIT study challenge not only traditional thinking but also existing guidelines from both the U.S. and Europe, all of which say that treating nonculprit arteries in STEMI patients may be harmful. MedPage Today reached out to a number of cardiologists for reactions, which are presented here.
Roxana Mehran, MD, Icahn School of Medicine, Mount Sinai Medical Center, New York City: "This trial is another one similar to PRAMI, supporting complete revascularization at the time of STEMI rather than infarct-related artery (IRA) PCI only.
"I have concerns, as this trial is also underpowered, the composite endpoint has many components, and none of the components are significant. There are few events in the patients which adds to the uncertainty of the results. Of note, it is unclear if the complete revasc was done at the same setting of STEMI or only during the index admission.
"This is clearly important."
Peter Block, MD, Emory Healthcare System, Atlanta: "CvLPRIT adds to our information, and the good news is that there are no 'negative' signals in this trial. The combined endpoint is what makes this trial positive -- none of the individual endpoints are significant, but all trend toward a favorable outcome for early PCI.
"Note that only slightly more than half of patients had PCI at the initial sitting, the remainder at the initial hospitalization. Interesting to see that in the extra slides the 'Per Protocol' population results once again indicate that the driver is repeat revascularization (perhaps no surprise in that those not initially treated end up with later PCI)."
Johanne Silvain, MD, Institute of Cardiology at the Pitié-Salpêtrière hospital group, Paris: "In my opinion, the CvLPRIT and the PRAMI trials are important trials as they support the fact that revascularization of the nonculprit artery in STEMI patients provides a better prognosis than medical optimal therapy.
"Both trials show a net clinical benefit in favor of revascularization by PCI when compared with medical treatment. However, it is not surprising to me that a STEMI patient with one or more severely narrowed coronary arteries treated only with a medical treatment, even the best ones, is at risk of recurrent events, especially repeat revascularization but also a new plaque rupture.
"In our center, we already considered for the last decade that such high-risk patients could not be adequately treated with optimal medical therapy, and staged revascularization is planned within the month after the STEMI. But sometimes it is done during the same hospitalization or, like in PRAMI and CvLPRIT, during the same procedure. It all depends on the severity of the lesions and the patient.
"Therefore, these results won't change our practice, but they definitely provide strong data to support such a strategy."
Sunil Rao, MD, Duke Cardiology, Durham, N.C.: "This is a very interesting trial showing that performing PCI of nonculprit arteries at the same time as the culprit artery during STEMI is beneficial. It is the second randomized study to challenge prior observational analyses that suggested harm with a multivessel PCI approach in these patients.
"Since we have two randomized trials showing similar outcomes, it would meet criteria for a high recommendation in the guidelines. We need to review the details of the CvLPRIT trial, in particular how the control arm patients were treated, before adopting this strategy wholesale.
"Some questions remain -- is there a difference between treating the nonculprit lesions during the primary PCI versus later in the hospitalization? What is the role of using FFR to guide the PCI of the nonculprit lesions? Overall, a very important study that will likely influence practice."
Sandeep Nathan, MD, University of Chicago Medicine, Chicago: "The CvLPRIT study is a very important addition to our growing body of knowledge regarding multivessel PCI in patients presenting with STEMI or MI with new LBBB and builds on the observations put forth by the PRAMI investigators in 2013.
"These data, on the backdrop of the Bainey meta-analysis, provide a robust and clear rationale for pursuing complete revascularization in the near term following P-PCI of the IRA in STEMI.
"Unanswered questions include the impact of this strategy in as yet unstudied populations such as high-risk NSTEACS, cardiogenic shock patients, and those with prior CABG. Nevertheless, the three studies taken together (PRAMI, CvLPRIT and Bainey et al.) should be practicing-changing in my opinion."
Deepak L. Bhatt, MD, MPH, Harvard Medical School, Boston: "I think this is potentially a practice-changing study. Most interventionalists have intuitively believed that STEMI patients should undergo nonculprit PCI 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."
Daniel Simon, MD, University Hospitals Case Medical Center, Cleveland: "The results of CvLPRIT lend strong support to the practice of performing complete revascularization of STEMI patients during the index admission. The timing of complete revascularization has been heretofore uncertain for cardiologists -- namely, at time of primary PCI, staged prior to discharge, staged for 30 days, or deferred pending stress-test defined ischemia. The results of the trial support at time of P-PCI or prior to discharge. This is the current practice of many interventional cardiologists, but we need to wait for further subgroup analysis to determine if revascularization at time of P-PCI is safe.
"All in all, the message is clear -- strive for complete revascularization to optimize outcomes for your STEMI patients."