Transcription
[Music] Welcome to EuroPCR 2025. My name is Angela Mcerney, and I'm an interventional cardiologist from Galway in Ireland. And I have the pleasure to be joined today by Natalyia Paneeria from McMaster in Canada and Matias Scottberg from Lund, Sweden. You're both very welcome.
So today we're here to speak about STEMI in patients with multi-vessel disease, and this is a really common presentation to our cath lab. So Matias, how has the approach to these patients evolved over time?
Yeah, thank you. Great being here. Well, back in the day, I'm thinking about 2010-2012, we really didn't have any way of knowing how to address these patients. And like you said, they're quite common in the cath lab. 40 to 50% of our patients do present with multi-vessel disease among patients. So, uh, there were two pivotal trials. First was the PRAMAT trial, and then it was the CULPRIT trial, and both of them actually showed a reduction in events in the complete revascularization group compared to those who were deferred in terms of non-culprit lesions. And more interesting, although the studies were quite small, they also found that death and MI seemed to be trending or were significantly lower in those trials, so they were not really powered for that. And it was angiographically guided PCI as well in those groups, so it's kind of an interesting thing: did we actually have guidance to say that the complete revascularization using angiographically guided guidance was something that we should do?
And in 2015, there was another study by the Copenhagen group called DANAMI 3, promoting FFR guidance in unculprit lesions. They also found a reduction in events, but it seemed to be more focused on the repeat revascularization or unplanned revascularization. So, not really the same picture that we saw in the other trials. And so the data speaks for using, you know, complete revascularization in the non-culprit lesions, but it doesn't really tell us what we should do. And then we had the COMPLETE trial, of course.
Yeah, so Natalia, of course, the COMPLETE trial, you were one of the PIs on that trial, and it really was practice-changing. It's the largest randomized control trial looking at complete versus culprit-only PCI. What were the main findings of that study?
Yeah, thank you for the question, and great to be here. So when we were working on COMPLETE, we randomized over 4,000 patients to culprit-only versus complete revascularization based on angiographic criteria. So, a lesion equal to or over 70% it was randomized to complete revascularization had PCI, and these studies show clear benefit in the complete revascularization arm. So for the primary outcome, that was cardiovascular death or myocardial infarction, we show a reduction of events by 26%. And in the secondary outcome, that was including ischemia-driven revascularization, we show around a 49% reduction of events. So it was a clear message that the patients benefit from complete revascularization.
And you also had a lot of interesting findings in from the COMPLETE trial as well using intracoronary imaging in these non-culprit lesions, which gave us a lot of information about the morphology of these non-culprit lesions and potentially maybe how we should be treating them. Do you want to tell us a bit about that sub-study?
Yes, we learned quite a bit when we did multi-vessel OCT imaging in those patients because over half of the non-culprit lesions had vulnerable plaques. So we got a lot of insights that the prevalence of vulnerability in these settings of patients is much higher, and that's really interesting in terms of how you might manage those patients and how you treat these non-culprit lesions because there still seems to be a little bit of controversy as to how to approach the treatment for these non-culprit lesions, whether that should be angiographically guided like in the COMPLETE study or whether physiology may be useful in this context.
Um, how do you approach these on a pragmatic point of view in your cath lab, Matias?
Yeah, thanks. So this is really about a preemptive strike. This is about treating lesions that not necessarily cause ischemia or cause symptoms because if we talk to patients, the majority of them actually don't have any symptoms prior to the STEMI. Um, so from a pragmatic point of view, what we try to do is if it's a focal lesion or if it's clearly significant using physiology, uh, or sometimes we use imaging as well. We leave that up to the operators of that site to decide. We typically use either of those modalities when it comes to revascularization to find what criteria that promotes revascularization versus deferral. We don't typically just use angiographic guidance. And the other thing is it's diffuse disease versus focal disease. We aim to try to know that we actually end up with a good result because we know the focal lesions are the ones that are more prone to rupture. So I think it's fair to say that what here in 2025, while we know that we should aim for complete revascularization in these patients, how we get there is a little controversial as to whether it's angiographically guided, physiologically guided, but we have some more trials coming down the line, and particularly the COMPLETE 2, Natalia.
Yeah, that's a it's a great study, and we are very happy working on it because once we transfer the message to our community that the patients need complete revascularization and angiography was an enough criteria to do complete, we also feel responsible to understand which of those lesions really are going to benefit from revascularization. So we have great tools as physiology, but by now we haven't been able really shown like if there is a real benefit of this, and we need a clear answer because we have had questionable results from some of the studies. So I think as a community, we need to know if physiology really has a place here. So in the COMPLETE 2, we are randomizing over 5,000 patients to angiographically guided PCI versus physiologically guided PCI. And I think this for sure is going to answer the question whether physiology is a good tool in this setting, yes or not. And we also had a very large imaging sub-study that is 1500 patients are going to have multi-vessel OCT. So we are going to have great, great information about these non-culprit lesions. It's like a natural history study again in these non-culprit lesions, and I think this for sure is going to answer that question. This is going to be really interesting data when we get it and hopefully will answer this for us definitively so that we actually know how to approach these patients.
But I guess one other thing, um, in terms of approaching these patients is when you treat these non-culprit lesions. Should we be doing it during the index procedure? Should we be doing it during the index hospitalization? Or should we bring the patient back in 6 weeks' time, for example, and then revascularize them? So the COMPLETE trial actually provided some data on that. It, it's actually said it was safe to do it either at index vascularization or up to 45 days. It showed there was actually no increase in events in delaying it. So it really comes down to pragmatic decision-making whether it was a large STEMI, it's a simple non-culprit lesion versus a complex non-culprit lesion. So either you can sort of stage depending on those risk factors for the patients in itself.
Yeah. So I think that's really important, isn't it? Is that you have to individualize it to the patient. That's really a pragmatic kind of viewpoint on it and how to approach these patients. So I think we've had a really good discussion. I think we've really kind of covered how complete revascularization benefits our patients, and we know this for sure. How we get there, we still need that data, and hopefully we're going to get it from the COMPLETE 2 trial. Um, and of course, when we revascularize these patients is um is also important and should be individualized. So I'd like to thank both of you for joining me here today, and I hope that you enjoy the rest of EuroPCR 2025.
Thank you. Thank you.