Left Anterior Descending Nonculprit Lesions and Clinical Outcomes in Patients With ST-Segment Elevation Myocardial Infarction.

Background: In the COMPLETE (Complete vs Culprit-Only Revascularization to Treat Multi-Vessel Disease After Early PCI for STEMI) trial, complete revascularization in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) reduced important outcomes compared with culprit-only percutaneous coronary intervention. Whether clinical outcomes in STEMI patients with MVD are influenced by the presence of a left anterior descending (LAD) nonculprit lesion (NCL) remains unknown.
Objectives: This study sought to compare: 1) cardiovascular outcomes among patients with an NCL in the proximal/mid-LAD to patients with an NCL in other locations; and 2) the benefit of NCL revascularization in patients with and without a proximal/mid-LAD NCL.
Methods: The COMPLETE trial enrolled patients presenting with STEMI and MVD to angiography-guided complete revascularization vs a culprit lesion-only strategy. All coronary angiograms were evaluated in a central core laboratory. In this prespecified subanalysis, treatment effect according to proximal/mid-NCL location was determined for the coprimary outcomes of: 1) cardiovascular death or new myocardial infarction; and 2) cardiovascular death, new myocardial infarction, or ischemia-driven revascularization. Cox proportional hazards models were performed with an interaction term for treatment allocation and NCL location.
Results: Of the 4,041 subjects in COMPLETE, 1,666 patients had a proximal/mid-LAD NCL (41.2%). The first coprimary outcome occurred in 8.5% (2.9%/y) of patients with a proximal/mid-LAD NCL vs 9.9% (3.4%/y) in those without (adjusted HR: 0.83; 95% CI: 0.67-1.03). Complete revascularization had a similar benefit in reducing the first coprimary outcome for patients with a proximal/mid-LAD NCL (7.7% vs 9.2%; HR: 0.85; 95% CI: 0.61-1.18) and those without (8.0% vs 11.9%; HR: 0.65; 95% CI: 0.50-0.86), with no differential treatment effect (interaction P = 0.235) CONCLUSIONS: Among patients presenting with STEMI and multivessel CAD, those with a proximal/mid-LAD NCL had similar event rates to those without. The benefit of complete revascularization between the groups was similar, with no evidence of heterogeneity.
Competing Interests: Funding Support and Author Disclosures The COMPLETE trial was funded by the Canadian Institutes of Health Research and through investigator-initiated research grants from AstraZeneca and Boston Scientific. Dr Pinilla-Echeverri has received research grant support from the Fundacion Alfonso Martin Escudero during the conduct of the study; and has received personal fees from Abbott and Conavi, outside of the submitted work. Dr Wood has received grants and other support from Edwards Lifesciences; and has received grants from Abbott and Boston Scientific, outside of the submitted work. Dr Bainey has received speaker honorarium from BI, HLS, and Novartis. Dr Schampaert has received speaker honorarium from Abbott, Boston Scientific, Medtronic, and Philips. Dr Džavík has received speaker honorarium from Medtronic. Dr Storey has received institutional research grants/support from AstraZeneca and Cytosorbents; and has received personal fees from Alfasigma, AstraZeneca, Boehringer Ingelheim/Lilly, Chiesi, Cytosorbents, Daiichi Sankyo, Idorsia, Novartis, Novo Nordisk, Pfizer, and Tabuk; has received personal fees from Bayer, Bristol-Myers Squibb/Pfizer, Haemonetics, Amgen, Portola, and Medscape; and has received grants and personal fees from AstraZeneca, Thromboserin, and Glycardial Diagnostics, outside of the submitted work. work. Dr Mehran has received institutional research payments from Abbott, Abiomed, Affluent Medical, Alleviant Medical, Amgen, AM-Pharma, Arena, AstraZeneca, AtriCure Inc, Biosensors, Biotronik, Boston Scientific, Bristol-Myers Squibb, CardiaWave, CeloNova, CERC, Chiesi, Cleerly Health Inc, Concept Medical, Cytosorbents, Daiichi Sankyo, Duke, Element Science, Essential Medical, Faraday, Idorsia Pharmaceuticals, Janssen, MedAlliance, Mediasphere, Medtelligence, Medtronic, MJH Healthcare, Novartis, OrbusNeich, Penumbra, PhaseBio, Philips, Pi-Cardia, PLx Pharma, Population Health Research Institute, Protembis, RecCor Medical Inc, RenalPro, RM Global, Sanofi, Shockwave, Vivasure, and Zoll; has received personal fees from Affluent Medical, Boehringer Ingelheim, Cardiovascular Research Foundation (CRF), Cordis, Daiichi Sankyo Brasil, E.R. Squibb & Sons, Esperion Science/Innovative Biopharma, EuropaGroup/Boston Scientific, Gaffney Events, Educational Trust, Henry Ford Health Cardiology, Ionis Pharmaceuticals, Lilly and Company, MedCon International, Novartis, NovoNordisk, PeerView Institute for Medical Education, TERUMO Europe N.V., Vectura, VoxMedia, WebMD, IQVIA, Radcliffe, and TARSUS Cardiology; serves on the AMA Scientific Advisory Board; is a SCAI Women in Innovations Committee member; has received faculty and CRF honoraria from JAMA Cardiology (Associate Editor) and ACC (BOT Member and SC Member CTR Program); and holds equity <1% in Elixir Medical, Stel, and CntrolRad (spouse). Dr Bossard has received consulting and speaker fees from Abbott Vascular, Abiomed, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Dachii Sankyo, Novartis, and SIS Medical. Dr Moreno has received personal fees from Medtronic, Boston Scientific, Abbott Vascular, Biotronik, Biosensors, Daiichi-Sankyo, Edwards, Amgen, and Bayer, outside the submitted work. Dr Campo has received research grants from SMT, GADA, Abbott Vascular, and Siemens Healthcare, outside the present work. Dr Cairns has received research grants from Boston Scientific and Edwards Lifesciences. Dr Mehta has received grants and other support from AstraZeneca; has received grants from Boston Scientific during the conduct of the study; and has received grants from AstraZeneca, outside of the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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