More Attention Should Be Paid to Less Severe Nonculprit Lesions—Reply

摘要

In Reply We thank Liang et al for their interest in our article.1 We agree with Liang et al that future research should address the question of how best to identify which nonculprit lesions require percutaneous coronary intervention (PCI). Advantages of an angiography-guided strategy are that it is widely available and, in the Complete vs Culprit-Only Revascularization Strategies to Treat Multivessel Disease After Early PCI for STEMI (COMPLETE) trial, led to the reduction of hard cardiovascular outcomes.1 The main benefit of an angiography-guided approach in the COMPLETE trial appeared to be in patients with more severely stenotic nonculprit lesions as determined by quantitative coronary angiography.2 A physiology-guided approach may objectively identify which angiographically significant lesions are also functionally significant, potentially reducing the number of nonculprit lesion PCI procedures. However, a key unresolved issue is that a physiology-guided strategy might lead to deferred PCI of lesions that, despite being fractional flow reserve negative, still have morphological features conferring a high risk for future cardiovascular events. The optical coherence tomography substudy of the COMPLETE trial showed that about one-half of patients had at least 1 obstructive nonculprit lesion containing complex vulnerable plaque (thin-capped fibroatheroma [TCFA]),3 and a recent prospective study of patients with diabetes demonstrated that among patients with fractional flow reserve–negative lesions, there was a more than 4-fold higher risk of cardiovascular events in patients with lesions containing vulnerable plaque morphology (TCFA) compared with more stable plaque morphology.4 Whether a physiology-guided strategy is as effective as an angiography-guided approach in patients with acute coronary syndrome is therefore not known. Two randomized trials directly comparing these approaches have shown mixed results.5,6 The COMPLETE-2 trial will address this question in a 5100 patient multinational trial where patients with acute coronary syndrome (ST-segment elevation myocardial infarction [STEMI] or non-STEMI) and multivessel coronary artery disease are randomized to receive complete revascularization with PCI using either an angiography-guided or a physiology-guided strategy. The trial will also have a large-scale optical coherence tomography substudy designed to determine whether vulnerable plaque morphology (TCFA) predicts future cardiovascular events. Until the results of COMPLETE-2 are available, we recommend that clinicians use either an angiography-guided or a physiology-guided strategy to achieve complete revascularization in patients with STEMI.