title: Infarct size following complete revascularization in patients presenting with STEMI: a comparison of immediate and staged in-hospital non-infarct related artery PCI subgroups in the CvLPRIT study.
abstract: BACKGROUND
  The CvLPRIT study showed a trend for improved clinical outcomes in the complete revascularisation (CR) group in those treated with an immediate, as opposed to staged in-hospital approach in patients with multivessel coronary disease undergoing primary percutaneous intervention (PPCI). We aimed to assess infarct size and left ventricular function in patients undergoing immediate compared with staged CR for multivessel disease at PPCI.
  
  
  METHODS
  The Cardiovascular Magnetic Resonance (CMR) substudy of CvLPRIT was a multicentre, prospective, randomized, open label, blinded endpoint trial in PPCI patients with multivessel disease. These data refer to a post-hoc analysis in 93 patients randomized to the CR arm (63 immediate, 30 staged) who completed a pre-discharge CMR scan (median 2 and 4 days respectively) after PPCI. The decision to stage non-IRA revascularization was at the discretion of the treating interventional cardiologist.
  
  
  RESULTS
  Patients treated with a staged approach had more visible thrombus (26/30 vs. 31/62, p = 0.001), higher SYNTAX score in the IRA (9.5, 8-16 vs. 8.0, 5.5-11, p = 0.04) and a greater incidence of no-reflow (23.3 % vs. 1.6 % p < 0.001) than those treated with immediate CR. After adjustment for confounders, staged patients had larger infarct size (19.7 % [11.7-37.6] vs. 11.6 % [6.8-18.2] of LV Mass, p = 0.012) and lower ejection fraction (42.2 ± 10 % vs. 47.4 ± 9 %, p = 0.019) compared with immediate CR.
  
  
  CONCLUSIONS
  Of patients randomized to CR in the CMR substudy of CvLPRIT, those in whom the operator chose to stage revascularization had larger infarct size and lower ejection fraction, which persisted after adjusting for important covariates than those who underwent immediate CR. Prospective randomized trials are needed to assess whether immediate CR results in better clinical outcomes than staged CR.
  
  
  BACKGROUND
  ISRCTN70913605 , Registered 24th February 2011.
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Cardiovascular Biomedical Research Unit, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK.
authors.forename: Jamal N
authors.initials: JN
authors.lastname: Khan
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Cardiovascular Biomedical Research Unit, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK.
authors.forename: Sheraz A
authors.initials: SA
authors.lastname: Nazir
authors.affiliation: Multidisciplinary Cardiovascular Research Centre and The Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
authors.forename: John P
authors.initials: JP
authors.lastname: Greenwood
authors.affiliation: Harefield Hospital, Royal Brompton and Harefield Foundation Trust, NIHR Cardiovascular Biomedical Research Unit, Middlesex, UK.
authors.forename: Miles
authors.initials: M
authors.lastname: Dalby
authors.affiliation: University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK.
authors.forename: Nick
authors.initials: N
authors.lastname: Curzen
authors.affiliation: Kettering General Hospital, Kettering, NN16 8UZ, UK.
authors.forename: Simon
authors.initials: S
authors.lastname: Hetherington
authors.affiliation: Royal Derby Hospital, Derby, UK.
authors.forename: Damian J
authors.initials: DJ
authors.lastname: Kelly
authors.affiliation: Multidisciplinary Cardiovascular Research Centre and The Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
authors.forename: Daniel
authors.initials: D
authors.lastname: Blackman
authors.affiliation: Leicester Clinical Trials Unit, University of Leicester, UK and Department of Mathematical Statistics and Actuarial Science, University of Leicester, University of the Free State, Bloemfontein, South Africa.
authors.forename: Arne
authors.initials: A
authors.lastname: Ring
authors.affiliation: University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK.
authors.forename: Charles
authors.initials: C
authors.lastname: Peebles
authors.affiliation: Harefield Hospital, Royal Brompton and Harefield Foundation Trust, NIHR Cardiovascular Biomedical Research Unit, Middlesex, UK.
authors.forename: Joyce
authors.initials: J
authors.lastname: Wong
authors.affiliation: Harefield Hospital, Royal Brompton and Harefield Foundation Trust, NIHR Cardiovascular Biomedical Research Unit, Middlesex, UK.
authors.forename: Thiagarajah
authors.initials: T
authors.lastname: Sasikaran
authors.affiliation: Norfolk and Norwich University Hospitals NHS Foundation Trust and Norwich Medical School, University of East Anglia, Norwich, UK.
authors.forename: Marcus
authors.initials: M
authors.lastname: Flather
authors.affiliation: The Heart Hospital, University College London Hospitals, London, UK.
authors.forename: Howard
authors.initials: H
authors.lastname: Swanton
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Cardiovascular Biomedical Research Unit, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK.
authors.forename: Anthony H
authors.initials: AH
authors.lastname: Gershlick
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Cardiovascular Biomedical Research Unit, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK. gpm12@le.ac.uk.
authors.forename: Gerry P
authors.initials: GP
authors.lastname: McCann
mesh_terms: D000368:Aged; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000473:pathology / Q000503:physiopathology / Q000628:therapy*; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009206:Myocardium / Q000473:pathology*; D018579:Patient Selection; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000379:methods*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012307:Risk Factors; D000072657:ST Elevation Myocardial Infarction / Q000000981:diagnostic imaging / Q000473:pathology / Q000503:physiopathology / Q000628:therapy*; D013318:Stroke Volume; D013997:Time Factors; D016896:Treatment Outcome; D016277:Ventricular Function, Left
keywords: Cardiovascular magnetic resonance; Infarct size; Multivessel disease; Myocardial infarction; Primary percutaneous coronary intervention