ABC | Volume 115, Nº2, August 2020

Short Editorial Is Complete Revascularization Truly Superior to Culprit-Lesion-Only PCI in Patients Presenting with ST-segment Elevation Myocardial Infarction? Christina Grüne de Souza e Silv a Clínica de Medicina do Exercício – CLINIMEX, Rio de Janeiro, RJ - Brazil Short editorial related to the article: Complete Revascularization Versus Treatment of the Culprit Artery Only in ST Elevation Myocardial Infarction: A Multicenter Registry Mailing Address: Christina de Souza e Silva • Rua Siqueira Campos 93. Postal Code 22031-072, Copacabana, RJ – Brazil E-mail: christina.g.dss@gmail.com Keywords Coronary Artery Disease; ST Elevation Myocardial Infarction; Myocardial Revascularization; Percutaneous Coronary Intervention. Primary percutaneous coronary intervention (PCI) is a standard therapy for patients with acute ST-segment elevation myocardial infarction (STEMI), and its goal is to restore blood flow to the coronary artery that is judged to be causing the myocardial infarction (known as the culprit artery). In up to half of such patients, major stenoses in one or more coronary arteries that are not responsible for the myocardial infarction (nonculprit lesions) may also be seen during the index angiography. 1 Since patients with acute STEMI and multivessel coronary artery disease (CAD) have worse clinical outcomes compared with patients with single-vessel disease, it has been questioned if PCI treatment of all significant nonculprit lesions following primary PCI (complete revascularization) could improve prognosis. A number of randomized clinical trials (RCT) have addressed this topic by comparing outcomes of patients with STEMI and multivessel CAD who underwent complete revascularization versus treatment of the culprit-lesion-only PCI (incomplete revascularization). Previously, intermediate- sized RCT 2-4 have shown that complete revascularization is safe and reduces the risk of composite outcomes, with results driven predominantly by the decreased risk of subsequent revascularization. Recently, the COMPLETE (Complete versus Culprit-Only Revascularization Strategies to Treat Multivessel Disease after Early Percutaneous Coronary Intervention [PCI] for STEMI) trial, 5 a larger RCT, showed that the risk of the composite outcome death from cardiovascular causes or recurrent myocardial infarction was lower in the complete revascularization group than in the culprit-lesion-only PCI group in patients presenting with STEMI, this benefit been driven by a reduction in new myocardial infarction. Moreover, in the largest meta-analysis of RCT performed to date addressing this topic, 6 complete revascularization was associated with a reduction in cardiovascular mortality compared with culprit-lesion-only PCI in patients with STEMI and multivessel CAD without cardiogenic shock at presentation (odds ratio, 0.69; 95% confidence interval [CI], 0.48-0.99; p=0.05). However, in order to provide balanced evidence base for clinical decision making, results from observational studies should complement the ones obtained from RCT. Although it is generally accepted that RCT are the “gold standard” for evaluation of medical therapies, these tend to evaluate interventions under ideal conditions among highly selected populations, limiting its provided evidence generalizability to clinical practice. In this issue of the journal Arquivos Brasileiros de Cardiologia , Cadore et al. 7 presents results from an observational study conducted in two Brazilian hospitals comparing complete revascularization vs. culprit-lesion-only PCI in patients with STEMI and multivessel CAD. From a total of 85 patients who had nonculprit lesions with stenosis of at least 70% on visual estimation (72% male, mean age of 62 years), 58 patients (68%) underwent complete revascularization. In the complete revascularization group, the minority of patients (10%) underwent nonculprit lesion PCI during the index PCI procedure for STEMI, while 52 patients (90%) underwent staged revascularization (i.e., PCI during a procedure separate from the index PCI procedure for STEMI), with a mean time between procedures of 13 days. After one year of follow-up, 8% of patients died. Primary composite outcome (cardiovascular mortality, newmyocardial infarction, recurrent angina) had occurred in six patients (10%) in the complete revascularization group as compared with ten patients (37%) in the culprit-lesion-only PCI group (odds ratio, 5.1; 95% CI, 1.6 to 16.1; p=0.005). Death due to cardiovascular causes occurred in two patients (3%) who underwent complete revascularization compared to five patients (19%) who underwent culprit-lesion-only PCI (odds ratio, 6.4; 95% CI, 1.2 to 35.3). Stroke, non-fatal cardiac arrest, major bleeding, or subsequent revascularization (the second composite outcome), occurred in three (5%) in the complete revascularization group as compared with six patients (22%) in the culprit-lesion-only PCI group (odds ratio, 5.2; 95% CI, 1.2 to 22.9; p=0.022); however, this difference was not significant after adjusting for potential cofounders. Although the aforementioned study provides optimistic outcomes favoring complete revascularization, larger observational studies that addressed the discussed issue have shown conflicting results. When analyzing data from the National Cardiovascular Data Registry, Cavender et al. 8 found that the overall in-hospital mortality rates were greater in patients undergoing complete revascularization (7.9% vs. 5.1%, p<0.01), even for patients presenting with cardiogenic shock. Similarly, the analysis of the EUROTRANSFER Registry 9 showed that patients who underwent nonculprit lesion PCI were at higher risk of 30-day and 1-year death compared to patients with culprit-lesion-only PCI, although this difference DOI: https://doi.org/10.36660/abc.20200640 238