Debra L. Beck, MSc, and Eugene Braunwald, MD

Insights from the COMPLETE trial

In the COMPLETE trial (Complete Versus Culprit-Only Revascularization to Treat Multi-Vessel Disease After Early PCI for STEMI), staged nonculprit lesion percutaneous coronary intervention (PCI) reduced major cardiovascular events in patients with ST-segment–elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD) compared to culprit lesion only PCI.

The trial included STEMI patients where fibrinolytic therapy was used as the mode of reperfusion for the index event (followed by rescue PCI in those randomly assigned to complete revascularization). Dehghani et al evaluated in a prespecified subanalysis whether consistent benefit was seen in the 303 COMPLETE trial patients who underwent a pharmacoinvasive strategy compared to the 3,738 patients who underwent primary PCI. Fibrin specific agents were used in 289 of 303 patients.

Culprit lesions were less complex in the pharmacoinvasive group compared to the primary PCI group (SYNTAX score 6.2 vs. 8.9; p<0.001, respectively), but nonculprit lesions were similar in complexity (SYNTAX score, 4.6 for both).

The first coprimary outcome of cardiovascular death or new myocardial infarction was reduced with complete revascularization both in the patients who underwent a pharmacoinvasive strategy (2.1%/y vs. 4.7%/y for culprit-only PCI; hazard ratio [HR], 0.45; p<0.05) and in patients who underwent primary PCI (2.7%/y vs. 3.6%/y for culprit-only PCI; HR, 0.77; p<0.05; interaction P=0.18).

The second coprimary outcome of cardiovascular death, new myocardial infarction, or ischemia-driven revascularization was also reduced with complete revascularization both in patients who underwent a pharmacoinvasive strategy (2.3%/y vs. 8.5%/y, HR, 0.28; p<0.05), and in patients who underwent primary PCI (3.2%/y vs. 6.0%/y, HR, 0.53; p<0.05; interaction p=0.07).

Summary

The investigators concluded that in STEMI patients with multivessel CAD, complete revascularization with multivessel PCI (staged PCI of nonculprit lesions) was superior to culprit lesion only PCI for the reduction of major cardiovascular events regardless of whether the primary mode of reperfusion was fibrinolysis or primary PCI.

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