Complete Revascularization in Myocardial Infarction
Definition
Complete revascularization in myocardial infarction (MI) is treatment of both the culprit (infarct-related) lesion and significant nonculprit lesions in patients with multivessel coronary artery disease. It is distinguished from culprit-only PCI, and the modern question is no longer whether to complete revascularization but how to select nonculprit lesions (angiography versus coronary physiology) and when to treat them (index procedure versus staged). It is a Class I recommendation in STEMI and in NSTE-ACS with multivessel disease (sources/complete-pci-multistars-ami-nejm-2023, rating: high).
Key Concepts
The core evidence: complete versus culprit-only
- Multiple randomised trials (PRAMI, CvLPRIT, DANAMI-3-PRIMULTI, COMPLETE) established that complete revascularization reduces recurrent MI and ischaemia-driven revascularization compared with culprit-only PCI, with COMPLETE additionally showing a reduction in cardiovascular death or MI (HR ~0.74) (sources/complete-pci-multistars-ami-nejm-2023, rating: high).
- The benefit is driven mainly by fewer nonfatal MIs and repeat revascularizations, not by a consistent mortality reduction (sources/complete-pci-multistars-ami-nejm-2023, rating: high).
- Complete revascularization is now Class I/A in STEMI and Class I/B-R in NSTE-ACS with multivessel disease (sources/CompletePCI-Elderly-FIRE-NEJM-2023, rating: very high).
Older patients — FIRE
- The FIRE trial randomised 1,445 patients aged ≥75 years (median 80; 36.5% women; 35.2% STEMI) to physiology-guided complete revascularization or culprit-only PCI (sources/CompletePCI-Elderly-FIRE-NEJM-2023, rating: very high).
- Primary composite (death, MI, stroke, ischaemia-driven revascularization at 1 year): 15.7% vs 21.0%; HR 0.73 (95% CI 0.57–0.93); P=0.01; NNT 19 (sources/CompletePCI-Elderly-FIRE-NEJM-2023, rating: very high).
- CV death or MI: 8.9% vs 13.5%; HR 0.64 (95% CI 0.47–0.88); NNT 22; all-cause death HR 0.70 (0.51–0.96); NNT to prevent one death 27 (sources/CompletePCI-Elderly-FIRE-NEJM-2023, rating: very high).
- Safety composite (contrast-associated AKI, stroke, BARC 3/4/5 bleeding): 22.5% vs 20.4%; HR 1.11 (0.89–1.37); P=0.37 — no significant excess, although individual components were numerically higher (sources/CompletePCI-Elderly-FIRE-NEJM-2023, rating: very high).
- The trial treated only physiologically significant nonculprit lesions: 49.6% had ≥1 significant nonculprit vessel, 50.1% underwent nonculprit PCI, and 50.9% of assessed nonculprit vessels were left untreated (sources/CompletePCI-Elderly-FIRE-NEJM-2023, rating: very high).
- The authors argue that older patients derive at least the same relative benefit as younger patients, with a larger absolute benefit because baseline risk is higher (sources/CompletePCI-Elderly-FIRE-NEJM-2023, rating: very high).
Selecting nonculprit lesions: angiography versus physiology
- Angiography-guided completion (treating high-grade visual or QCA stenoses) was the strategy of COMPLETE, which used FFR in <1% of patients and reduced CV death/MI (sources/ffrpci-mi-fullrevasc-nejm-2024, rating: very high).
- Wire-FFR-guided completion in FULL REVASC was neutral for death/MI/unplanned revascularization (19.0% vs 20.4%; HR 0.93; P=0.53) and was associated with more stent thrombosis (HR 2.80); 40% of the complete arm had all nonculprit lesions deferred (sources/ffrpci-mi-fullrevasc-nejm-2024, rating: very high).
- FIRE used a mixture of wire-based hyperaemic/non-hyperaemic indices and QFR, with a ≤0.80/≤0.89 threshold, and won — but the comparator was culprit-only, not angiography-guided completion, so it does not settle the physiology-versus-angiography question (sources/CompletePCI-Elderly-FIRE-NEJM-2023, rating: very high).
- AIR-STEMI tested angiography-derived physiology against angiography-guided completion directly in STEMI and found physiology superior (8.9% vs 13.7%; HR 0.62), with a better safety composite (sources/AIR-STEMI-NEJM-2026, rating: very high).
- The reconciling variable across FLOWER-MI, FRAME-AMI, FULL REVASC and AIR-STEMI appears to be when and how physiology is applied — integrated into the index procedure and used for lesion selection and PCI planning, rather than as a binary gate in a staged procedure (sources/AIR-STEMI-NEJM-2026, rating: very high).
Timing: immediate versus staged
- MULTISTARS AMI (n=840, STEMI): immediate multivessel PCI reduced the 1-year composite versus staged PCI within 19–45 days (8.5% vs 16.3%; RR 0.52; P<0.001), driven by nonfatal MI and unplanned revascularization in the first 45 days; after day 45 the curves converged (sources/complete-pci-multistars-ami-nejm-2023, rating: high).
- BIOVASC extended immediate complete revascularization to the full ACS spectrum and showed noninferiority to a staged strategy (sources/complete-pci-multistars-ami-nejm-2023, rating: high).
- iMODERN (n=1,146, STEMI) found immediate iFR-guided PCI was not superior to deferred MRI-guided PCI at 3 years (9.3% vs 9.8%; HR 0.95; P=0.81), although iFR treated more patients (42.6% vs 18.7%) (sources/iFR-PPCI-iMODERN-NEJM-2026, rating: very high).
- Guidelines remain cautious: immediate single-procedure multivessel PCI is Class IIb/B-R, reflecting the discordance between MULTISTARS AMI and iMODERN (sources/complete-pci-multistars-ami-nejm-2023, rating: high).
Exceptions and unresolved scenarios
- Cardiogenic shock: culprit-only PCI is recommended; multivessel PCI at the index procedure increased death or renal failure in CULPRIT-SHOCK and is Class III: Harm (sources/complete-pci-multistars-ami-nejm-2023, rating: high).
- Left main disease, chronic total occlusion, prior CABG: excluded from the major trials; timing and completeness are not established (sources/complete-pci-multistars-ami-nejm-2023, rating: high).
- NSTEMI: FIRE provides the strongest evidence in older NSTEMI patients; in younger NSTEMI the evidence is extrapolated from STEMI trials and BIOVASC (sources/CompletePCI-Elderly-FIRE-NEJM-2023, rating: very high).
Contradictions / Open Questions
- Physiology versus angiography guidance remains unsettled despite AIR-STEMI. FULL REVASC (wire FFR) was neutral while COMPLETE (angiography) was positive, suggesting FFR may defer vulnerable plaques; AIR-STEMI then showed angiography-derived physiology beating angiography. The differences may lie in the index-procedure setting, the use of physiology for PCI planning as well as lesion selection, or the specific index used — none of which the trials separate (sources/ffrpci-mi-fullrevasc-nejm-2024, rating: very high; sources/AIR-STEMI-NEJM-2026, rating: very high).
- Does complete revascularization reduce mortality? Individual trials show inconsistent mortality effects. FIRE found an all-cause mortality reduction (HR 0.70) in elderly patients, and COMPLETE found a CV death/MI reduction, but FULL REVASC and iMODERN did not. The mortality signal may depend on population risk and follow-up duration (sources/CompletePCI-Elderly-FIRE-NEJM-2023, rating: very high).
- More stents versus fewer events. FFRangio-style physiology and FIRE's selective approach both leave many lesions untreated, yet FFRangio led to more PCI than wire physiology. Whether extra stents add benefit or harm beyond 1 year is unknown, and FULL REVASC's excess stent thrombosis is a caution (sources/ffrangio-allrise-nejm-2026, rating: very high; sources/ffrpci-mi-fullrevasc-nejm-2024, rating: very high).
- The FIRE result may not transfer to angiography-guided practice. Its benefit was obtained with physiology in 97.2% of patients and a specific ultrathin biodegradable-polymer stent; the authors themselves caution against extrapolating to angiography-guided completion (sources/CompletePCI-Elderly-FIRE-NEJM-2023, rating: very high).
- Optimal timing window and the value of completeness in NSTEMI are still unresolved; trials have used windows from the index procedure to 6 weeks, and none directly compares immediate versus staged angiography-guided PCI using only hard outcomes (sources/complete-pci-multistars-ami-nejm-2023, rating: high; sources/iFR-PPCI-iMODERN-NEJM-2026, rating: very high).
Connections
- Related to concepts/Multivessel-PCI-STEMI-Timing — timing of nonculprit PCI in STEMI
- Related to concepts/Fractional-Flow-Reserve — wire-based physiological lesion selection
- Related to concepts/Angiography-Based-Coronary-Physiology — QFR, vFFR and FFRangio as wire-free alternatives
- Related to concepts/NSTEMI-Elderly-Invasive-Strategy — invasive management of older NSTEMI patients
- Related to entities/Acute-Coronary-Syndrome — clinical context
- Related to concepts/Intracoronary-Imaging-Guided-PCI — imaging guidance of nonculprit PCI