Findings From CvLPRIT Trial Published

March 9, 2015—In the Journal of the American College of Cardiology, Anthony H. Gershlick, MD, et al published findings from CvLPRIT (Complete Versus Lesion-Only Primary PCI trial), which is an open-label randomized study in the United Kingdom comparing complete revascularization at index admission versus treatment of the infarct-related artery (IRA) only (2015;65:963–972). The background of the study is that the optimal management of patients found to have multivessel disease while undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction is uncertain.

As summarized in the Journal of the American College of Cardiology, 296 patients at seven centers in the United Kingdom provided verbal assent and underwent coronary angiography. The patients were randomized through an interactive voice-response program to either in-hospital complete revascularization (n = 150) or IRA-only revascularization (n = 146). Complete revascularization was performed either at the time of primary PCI or before hospital discharge. Randomization was stratified by infarct location (anterior/nonanterior) and symptom onset (≤ 3 hours or > 3 hours). The primary endpoint was a composite of all-cause death, recurrent myocardial infarction, heart failure, and ischemia-driven revascularization within 12 months.

The investigators reported that the patient groups were well matched for baseline clinical characteristics. The primary endpoint occurred in 10% of the complete revascularization group versus 21.2% in the IRA-only revascularization group (hazard ratio, 0.45; 95% confidence interval, 0.24–0.84; P = .009). A trend toward benefit was seen early after complete revascularization (P = .055 at 30 days). Although there was no significant reduction in death or myocardial infarction, a nonsignificant reduction in all primary endpoint components was seen. There was no reduction in ischemic burden on myocardial perfusion scintigraphy or in the safety endpoints of major bleeding, contrast-induced nephropathy, or stroke between the groups.

In patients presenting for primary PCI with multivessel disease, index admission complete revascularization significantly lowered the rate of the composite primary endpoint at 12 months compared with treating only the IRA. In such patients, inpatient total revascularization may be considered, but larger clinical trials are required to confirm this result and specifically address whether this strategy is associated with improved survival, concluded the investigators in Journal of the American College of Cardiology.

The CvLPRIT results were first presented in September at the European Society of Cardiology’s ESC Congress 2014 in Barcelona, Spain. 

After presenting these results, the American College of Cardiology announced that it had withdrawn its Choosing Wisely recommendation that patients and caregivers examine whether the practice of complete revascularization of all significantly blocked arteries is truly necessary. The society stated that it was responding to this new science showing that complete revascularization of all significantly blocked arteries leads to better outcomes in some heart attack patients and stated that these results reinforce data from the PRAMI (Preventive Angioplasty in Myocardial Infarction) trial, which show that stenting all coronary arteries with major stenoses improves outcomes. PRAMI was presented at the ESC Congress 2013 in Amsterdam, the Netherlands, and was published in The New England Journal of Medicine (2013;369:1115–1123).