The last 15 years have seen the field of percutaneous coronary interventions (PCIs) really come into its own, with PCIs now the go-to therapy for patients experiencing an ST segment elevated myocardial infarction (STEMI). The clinical data is very clear that re-vascularizing the artery causing a STEMI is a life-saving intervention. However, while identifying this so-called culprit lesion by angiogram in order to treat it, interventional cardiologists often notice additional lesions elsewhere in the coronary vasculature, and have to make a decision about whether to place additional stents at these other sites.
Whether to stent additional lesions has been the subject of some controversy. Some clinical guidelines initially recommended leaving well enough alone on the basis of retrospective, non-randomized trials which suggested worse outcomes for patients subjected to complete revascularization. More recent (randomized) clinical data, however, has begun to turn the tide in favor of treating non-culprit lesions.
Initially presented at the European Society of Cardiology last fall, and published in the March 17th issue of JACC, the CvLPRIT trial suggests interventional cardiologists should be proactive and go after additional, non-culprit lesions identified while treating a STEMI to achieve better outcomes for the patient. The CvLPRIT trial is actually the second randomized trial to address this question the PRAMI trial reached a similar conclusion a year ago.
While the clinical data increasingly supports intervening in non-culprit lesions, the question remains; how big of a change will we see in the cath lab Will we see an uptick in stent usage in the coming years as additional lesions are treated?
There are some reasons to be cautious. We shouldn't forget that there has been some pressure recently on the number of stents employed during an average PCI. This is particularly true in the US, where the over-stenting controversy has negatively impacted stent sales, but also in countries fractional flow reserve (FFR) measurements have seen high uptake, since FFR frequently suggests a lesion identified by angiogram may not be worth stenting. It could also be that the additional time and resources required to treat non-culprit lesions could further limit changes in clinical practice.