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Complete Revascularization in Older Patients With STEMI
Quick Takes
- The current study was an individual patient-level meta-analysis from seven randomized clinical trials evaluating long-term benefits of complete revascularization compared to culprit-only revascularization for the clinical endpoints of all-cause death, MI, or ischemia-driven revascularization.
- Complete revascularization was associated with reduction in the primary endpoint up to 4 years (HR, 0.78; 95% CI, 0.63-0.96) but not beyond.
- Patients undergoing complete revascularization had a more sustained benefit of CV death or MI for the longest available follow-up (HR, 0.76; 95% CI, 0.58-0.99) but not for all-cause death.
Study Questions:
What are long-term clinical benefits of complete versus culprit-only revascularization among ST-segment elevation myocardial infarction (STEMI) patients aged ≥75 years?
Methods:
PubMed, Embase, and the Cochrane database, were systematically searched to identify randomized clinical trials (RCTs) comparing complete versus culprit-only revascularization. Individual patient-level data were collected from the relevant trials. The primary endpoint was death, myocardial infarction (MI), or ischemia-driven revascularization. The secondary endpoint was cardiovascular (CV) death or MI.
Results:
Data from seven RCTs, encompassing 1,733 patients (917 randomized to culprit-only and 816 to complete revascularization), were analyzed. The median age was 79 [77-83] years; 595 (34%) were females. Follow-up ranged from a minimum of 6 months to a maximum of 6.2 years (median 2.5 [1-3.8] years). Complete revascularization reduced the primary endpoint up to 4 years (hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.63-0.96), but not at the longest available follow-up (HR, 0.83; 95% CI, 0.69-1.01). Complete revascularization significantly reduced the occurrence of CV death or MI at the longest available follow-up (HR, 0.76; 95% CI, 0.58-0.99). This was observed even when censoring the follow-up at each year. Long-term rate of death did not differ between complete and culprit-only revascularization arms.
Conclusions:
In this individual patient data meta-analysis of older STEMI patients with multivessel disease, complete revascularization reduced the primary endpoint of death, MI, or ischemia-driven revascularization up to 4 years. At the longest follow-up, complete revascularization reduced the composite of CV death or MI, but not the primary endpoint.
Perspective:
Long-term benefits of complete revascularization among patients with STEMI remains debated, especially in older adults. The current study was an individual patient-level meta-analysis from seven RCTs evaluating long-term benefits of complete revascularization compared to culprit-only revascularization for the clinical endpoints of all-cause death, MI, or ischemia-driven revascularization. Complete revascularization was associated with reduction in the primary endpoint up to 4 years (HR, 0.78; 95% CI, 0.63-0.96) but not beyond. Patients undergoing complete revascularization had a more sustained benefit of CV death or MI for the longest available follow-up (HR, 0.76; 95% CI, 0.58-0.99) but not for all-cause death. Findings are limited by study design and disparate follow-up durations in the RCT included in the analysis but do make an important contribution to guiding management of multivessel coronary artery disease in older patients.
Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Vascular Medicine, Cardiac Surgery and SIHD, Interventions and Vascular Medicine, Chronic Angina
Keywords: Geriatrics, Myocardial Revascularization, ST Elevation Myocardial Infarction
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