Dr. C. Michael Gibson and Dr. Shamir Mehta Review: Does Complete Revascularization Truly Reduce CV Death and MI?

Live from AHA 2025, in this new SnackableHealth™, Dr. C. Michael Gibson sits down with Dr. Shamir Mehta to unpack the largest individual-patient-data meta-analysis ever conducted on complete versus culprit-only revascularization in ACS. By pooling six multicenter randomized trials, the Complete Revascularization Trialists’ Collaboration assembled a dataset of 8,836 patients, 910 cardiovascular deaths or new MIs, and 678 total deaths — finally providing the statistical power missing from individual studies to answer the long-standing question of whether complete revascularization truly reduces mortality.

The signal could not be clearer. Complete revascularization reduced cardiovascular death or new MI by 26% (HR 0.74, p < 0.0001), with extremely tight confidence intervals confirming the consistency of the effect. The most practice-changing finding, however, is the 24% reduction in cardiovascular mortality alone, a result never previously demonstrated with this level of robustness. In absolute terms, CV mortality fell from 4.6% to 3.6% — a 1% absolute reduction — meaning that 99 complete primary PCIs are needed to save one life, and only 41 to prevent one composite event of CV death or new MI. Importantly, all of the mortality benefit comes from fewer cardiovascular deaths; non-CV mortality curves were entirely superimposable, reinforcing the biological plausibility of the effect.

The benefit was consistent regardless of whether the index event was STEMI or NSTEMI, although the NSTEMI subgroup remains smaller (about 1,200 of the 8,800 patients), highlighting the need for further dedicated evidence. The analysis also compared angiography-guided selection of non-culprit lesions (≥70% stenosis) versus physiology-guided approaches (FFR/iFR), showing benefit with both strategies and no interaction between them. COMPLETE-2 — currently enrolling 5,100 patients with OCT imaging in 1,500 — is expected to answer the “how to select lesions” question definitively.

Dr. Gibson noted, from reviewing more than 2,500 primary PCI films, that many cases reveal a tendency to stent the most obvious lesion, while the truly unstable or thrombotic segment may in fact be in the non-culprit artery. This meta-analysis offers strong scientific validation for that clinical intuition physicians often develop over decades. Both experts also emphasized that these results do not apply to patients in cardiogenic shock, who were excluded from all contributing trials.

Ultimately, this IPD meta-analysis delivers a definitive conclusion: complete revascularization saves lives, reduces recurrent MI, and cements the Class I-A guideline recommendation with unprecedented statistical strength. The question of “whether” to pursue complete revascularization is now settled; what remains is fine-tuning “how” to select the right lesions — an answer that upcoming trials are poised to provide.