Revascularizing Vessels After STEMI Sees Durable Gains

For patients with ST-elevation myocardial infarction, complete revascularization of all vessels with stenosis appears to be a more effective long-term approach than targeting culprit arteries alone, according to a 10-year follow-up analysis of a Danish study.

The new findings come from an analysis of patients in the DANAMI-3-PRIMULTI trial, one of several studies between 2017 and 2024 to show the value of complete revascularization, which is now recommended for patients with STEMI and multivessel disease by both US and European guidelines. But those recommendations are based on shorter-term outcomes. The question remained how long the benefits would last, said Thomas Engstrøm, MD, PhD, professor and senior consultant in the Department of Invasive Cardiology at The Heart Center, part of the University of Copenhagen, Copenhagen, Denmark.  

The latest data, published May 20 in the Journal of the American College of Cardiology, span the longest to date of a study of complete vs culprit-artery revascularization, he said.

“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, one of the authors of the original study as well as 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 included all 627 patients in the original study, 313 of whom were randomized to culprit-artery revascularization and 314 to complete revascularization. Engstrøm said he and his colleagues manually reviewed hospital records for each patient to ensure they captured any events.

Which Benefits Last?

Complete revascularization was associated with better outcomes for a combination of death, recurring myocardial infarction, and recurring revascularization (hazard ratio, 0.76 compared with culprit-artery revascularization), according to the researchers. The ability of complete revascularization to prevent further revascularization accounted for the bulk of the difference, with a hazard ratio of 0.62.

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

But other outcomes showed less benefit and were not statistically significant. All-cause mortality was almost the same in both groups (hazard ratio, 0.96). Cardiovascular mortality showed a 20% reduction with complete revascularization, but this difference was not statistically significant due to the low number of patients, Engstrøm said. Rates of recurrent myocardial infarction and definite stent thrombosis also were essentially the same in each group, the researchers found (odds ratio, 0.90 for both outcomes).

Open Questions

Other studies have shown benefit for mortality and myocardial infarction following complete revascularization. The COMPLETE trial in 2019 showed benefits for a combined outcome of cardiovascular death or myocardial infarction after 3 years (hazard ratio, 0.74), driven by a lower rate of recurrent myocardial infarction (hazard ratio, 0.68).

At least two factors may explain the discrepancy in findings, Engstrøm said. The COMPLETE trial was much larger, with more than 4000 patients. “It was more adequately powered to show effects,” Engstrøm said.

“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.” DANAMI-3-PRIMULTI did not analyze patient outcomes by severity of lesions, whereas the COMPLETE trial did, he noted.

In addition, revascularization was guided by different methods in the two trials. In DANAMI-3-PRIMULTI, complete revascularization was guided by fractional flow reserve (FFR) measurements, whereas the COMPLETE trial involved 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 said.

DANAMI-3-PRIMULTI did not measure FFR in patients in whom revascularization involved only the culprit artery, Fearon said. 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 underway is looking at whether FFR or angiography is a better way to measure blood flow in vessels, Engstrøm said.

“The COMPLETE trial showed us that angiography-guided complete revascularization is superior to culprit-artery revascularization,” said Fearon, who is on the steering committee 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.”

Studies to date of complete vs culprit-vessel revascularization show “a very uniform arrow that leads to complete revascularization,” Engstrøm said, “but there are some corners that have not been shed light on.”

Engstrøm is on the advisory board for Novo Nordisk and Abbott Medical. He has received speaker’s fees from Abbott Medical, Boston Scientific, and Novo Nordisk. Fearon receives institutional research support from Abbott, CathWorks, and Medtronics. He has received consulting fees or honoraria from Shockwave Medical and from Edwards Lifesciences, and he has stock options in Heartflow. 

Carolyn Brown is a freelance scientific and biomedical reporter in Ottawa, Canada.