Stents for All Clogged Arteries Beneficial Following a Heart Attack

Shamir Meta, MD

New research suggests opening all clogged arteries with stents after a serious heart attack is superior to only opening the single clogged artery that caused the heart event.

In a new study, called the COMPLETE trial, investigators representing 130 hospitals in 31 countries, found that opening all blockages is more beneficial, leading to a 26 percent reduction in the patient’s risk of dying or having a recurrent heart attack, when compared with treating the only blockage responsible for the heart attack.

Study leader Shamir R. Mehta, MD, of the Population Health Research Institute (PHRI) of McMaster University and Hamilton Health Sciences, presented new data on the 4041-patient study as a late-breaking clinical science session at the European Society of Cardiology (ESC) Congress together with the World Congress of Cardiology in Paris.

"Given its large size, international scope and focus on patient-centered outcomes, the COMPLETE trial will change how doctors treat this condition and prevent many thousands of recurrent heart attacks globally every year,” Mehta said in a statement.

The study included patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease who had undergone successful culprit-lesion percutaneous coronary intervention to a strategy of either complete revascularization with PCI of angiographically significant nonculprit lesions or no further revascularization.

Over the median of 3 years, a second heart attack or cardiovascular death reduced to 7.8% of the patients who had the complete revascularization, while 10.5% of those who had a stent only for the artery that caused the heart attack had a second heart attack or cardiovascular death (HR, .74; 95% CI, .60-.91; P = .004).

The second coprimary outcome had occurred in 8.9% of patients in the complete-revascularization group as compared with 16.7% in the culprit-lesion-only PCI group (HR, .51; 95% CI, .43-.61; P < .001).

The benefit was even more pronounced when factoring in other untoward event such as severe chest pain necessitating a repeat stenting procedure.

The first coprimary outcome was the composite of cardiovascular death or myocardial infarction, while the second coprimary outcome was the composite of cardiovascular death, myocardial infarction, or ischemia-driven revascularization.

Approximately 50% of all heart attack victims have some additional clogged arteries in addition to the artery that caused the heart attack. In the past, doctors focused on opening the artery responsible for the heart attack, while leaving all the other blockages for treatment with medication alone.

Mehta said while it has been known opening a single blocked artery with stents was beneficial, it was unknown whether additional stents to clear the other clogged arteries prevented further death or heart attacks.

"This study clearly showed that there is long term benefit in preventing serious heart-related events by clearing all of the arteries. There was also no major downside to the additional procedures," said Mehta.

The study represents the first large, randomized, international trial showing a reduction in major outcomes using the multiple stent approach.

"The benefits emerged over the long term and were similar when the additional stent procedures were done any time in the first 45 days after the heart attack," said Mehta.

The study, "Complete Revascularization with Multivessel PCI for Myocardial Infarction," was published in the New England Journal of Medicine.