For individuals experiencing ST-elevation myocardial infarction (STEMI), addressing all vessels with stenosis through complete revascularization appears too yield more lasting benefits compared to treating only the culprit arteries. This conclusion stems from a decade-long follow-up analysis of a Danish clinical trial.

the findings are derived from an examination of participants in the Danami-3-Primulti trial. This study is part of a series conducted between 2017 and 2024 that highlights the advantages of complete revascularization. Current guidelines in both the US and Europe advocate for this approach in STEMI patients with multivessel disease. Though, these recommendations primarily consider short-term outcomes. The enduring nature of these benefits remained uncertain, according to Thomas Engstrøm, MD, PhD, a professor and senior consultant in the Department of Invasive Cardiology at The Heart Center, University of Copenhagen, Denmark.

The latest data, published May 20 in the Journal of the American College of Cardiology, represents the most extended study period to date comparing complete versus culprit-artery revascularization, he noted.

“A short term of 1 or 3 years is good to see if a treatment works, but what’s more important for patients is whether it is durable,” said Engstrøm, an author of both the original study and the follow-up analysis. “Many of our patients are not that old; 10 years is not that long for a patient who has an acute myocardial infarction at 60 years of age.”

The follow-up encompassed all 627 patients from the initial study, with 313 individuals randomly assigned to culprit-artery revascularization and 314 to complete revascularization. Engstrøm stated that he and his colleagues meticulously reviewed hospital records for each patient to ensure thorough event capture.

Which Benefits Endure?

Researchers found that complete revascularization correlated with improved outcomes regarding death, recurrent myocardial infarction, and repeat revascularization (hazard ratio, 0.76 compared to culprit-artery revascularization). The preventive effect of complete revascularization on the need for subsequent revascularization largely accounted for this difference, showing a hazard ratio of 0.62.

William Fearon, MD, a professor of medicine at Stanford University, chief of interventional cardiology at Stanford University School of medicine, and chief of the cardiology section at the VA Palo Alto Health Care System, who was not involved in the trial, commented that the results “add further support for complete revascularization. It shows ther’s a persistent benefit, especially in regard to the need for repeat vascularization.”

“A short term of 1 or 3 years is good to see if a treatment works, but what’s more important for patients is whether it is durable.”

However, other outcomes demonstrated less pronounced benefits and lacked statistical significance. all-cause mortality was nearly identical in both groups (hazard ratio, 0.96). Cardiovascular mortality showed a 20% reduction with complete revascularization, but this difference did not reach statistical significance due to the limited patient sample size, according to engstrøm. Rates of recurrent myocardial infarction and definite stent thrombosis were also substantially similar across both groups (odds ratio, 0.90 for both outcomes).

Unresolved Questions

Previous studies have indicated benefits for mortality and myocardial infarction following complete revascularization. The COMPLETE trial in 2019 demonstrated benefits for a combined outcome of cardiovascular death or myocardial infarction after 3 years (hazard ratio, 0.74), primarily driven by a reduced rate of recurrent myocardial infarction (hazard ratio, 0.68).

Engstrøm suggested that at least two factors might explain the discrepancies in findings. The COMPLETE trial was significantly larger, involving over 4000 patients. “It was more adequately powered to show effects,” Engstrøm noted.

“I think the [DANAMI-3-PRIMULTI] study was relatively small relative to some others,” Fearon said. “So that limits the ability to look at specific endpoints that have a lower incidence.”

“What we’re learning is that, for harder endpoints like [myocardial infarction] the benefit is really in more severe lesions.” He also pointed out that DANAMI-3-PRIMULTI did not analyze patient outcomes based on the severity of lesions, whereas the COMPLETE trial did.

additionally, the two trials employed different methods for guiding revascularization. DANAMI-3-PRIMULTI used fractional flow reserve (FFR) measurements to guide complete revascularization, while the COMPLETE trial relied on angiography-guided revascularization.

“The COMPLETE trial used a less stringent way of defining the lesions,by angiography.These lower-grade stenoses were not identified by FFR,” Engstrøm explained.

Fearon noted that Danami-3-Primulti did not measure FFR in patients in whom revascularization involved only the culprit artery.Another study reported in 2017, Compare-acute, measured FFR in both complete and culprit-artery revascularization groups and found a lower FFR was associated with a higher rate of subsequent events, he said.

The COMPLETE-2 trial,currently in progress,aims to determine whether FFR or angiography is a superior method for assessing blood flow in vessels,according to Engstrøm.

“The COMPLETE trial showed us that angiography-guided complete revascularization is superior to culprit-artery revascularization,” said Fearon, a steering commitee member for the COMPLETE-2 study. “The other trials showed us that FFR-guided complete revascularization is superior, but we don’t know whether FFR-guided complete revascularization is superior to angiography-guided complete revascularization.”

Engstrøm stated that studies comparing complete versus culprit-vessel revascularization to date reveal “a very uniform arrow that leads to complete revascularization,” but “there are some corners that have not been shed light on.”