Here's the scenario: You have a patient with ST-elevation myocardial infarction (STEMI) involving the left anterior descending (LAD) artery, who also has significant stenosis of the right coronary artery (RCA). The patient is to undergo percutaneous coronary intervention (PCI) for the of the LAD, but what do you do with the RCA? Do you treat, or leave it behind?
This was the question that the Complete Versus culprit-Lesion only PRimary PCI Trial (CVLPRIT), the results of which were presented at the 2014 European Society of Cardiology Congress in Barcelona, Spain in September 2014, aimed to answer.
CvLPRIT was an popen-label, prospective, randomized, multicentre trial that included 300 STEMI patients who also had lesions in a non-infarct-related artery. The lesion in the non-infarct-related artery had to be more than 70% in a single plane, or more than 50% in orthogonal planes. All patients received PCI treatment of the culprit lesion. The control group (n=150) did not receive PCI treatment for the non-infarct-related artery, while the treatment group received PCI to treat the second lesion. The second PCI had to be performed during the same hospital admission, and 59% of patients in the treatment group received the second PCI in the same sitting to minimize loss to follow-up and a second puncture.
Results shows that those in the treatment group had a 55% reduction (p=0.009) in composite major adverse cardiac events (MACEs) at 12 months (intent-to-treat analysis). in patients who had complete revascularization at the time of their index admission.
Furthermore, treating both lesions at the same time, although more time-consuming, was not associated with any excess bleeding, contrast-induced nephropathy, or other safety concerns.
The evidence used in guidelines stating that treating the uninvolved artery was associated with harm, were mostly from registries, which has inherent bias: those who received more aggressive treatment were generally sicker, and would have graver outcomes. In contrast, CvLPRIT was a prospective, randomized controlled trial, which minimizes bias.
The authors did not recommend outright PCI for all patients with non-infarct-related lesions. Instead, physicians should still use clinical judgement in deciding whether to treat uninvolved stenosed arteries, based on the severity of stenosis and the condition of the patient.