Benefits of complete revascularization confirmed in older patients with ST-elevation myocardial infarction

The benefits of complete revascularization over culprit-only coronary artery revascularization were confirmed in older patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease over the first 4 years, according to late-breaking research presented in a Hot Line session today at ESC Congress 2024.

“Treating culprit and non-culprit lesions with complete revascularization is the standard treatment for patients with STEMI and multivessel disease. However, this strategy is currently underused in older patients and the benefits of complete revascularization compared with culprit-lesion only revascularization remain a topic for debate.

“We performed the EARTH-STEMI meta-analysis of data from patients aged 75 years or older included in several different trials and were able to confirm the benefits of complete revascularization in the first 4 years after the event,” explained study presenter, Professor Gianluca Campo from the University Hospital of Ferrara, Ferrara, Italy.

Recent trials, such as the COMPLETE trial2 demonstrated the superiority of complete revascularization in patients with STEMI and multivessel disease. The FIRE trial then confirmed the benefits in older patients at 1 year but included patients with either STEMI or non-STEMI.3 The individual patient-level EARTH-STEMI meta-analysis combined data on outcomes from older patients with STEMI from several trials to expand the knowledge base in a larger group of older patients with longer follow-up.

In the meta-analysis, databases were systematically searched to identify randomized clinical trials comparing complete vs. culprit-only revascularization in patients with MI and multivessel disease. Individual patient-level data were collected from the selected trials for patients aged 75 years or older with STEMI. The primary endpoint was a composite of death, myocardial infarction, and ischemia-driven revascularization. The key secondary endpoint was cardiovascular death and myocardial infarction.

In total, seven trials were identified: COMPLETE,2 FIRE,3 FULL REVASC,4 DANAMI-3–PRIMULTI,5 COMPARE ACUTE,6 Hamza et al.,7 and CvLPRIT.8 Around one-fifth (19%) of the patients included in these trials were aged 75 years or older.

Of the 1,733 patients aged 75 years or older included in the meta-analysis, 816 received complete revascularization and 917 received culprit-only revascularization. The median age was 79 years old and 15% were aged more than 85 years. Around one-third were female (34%). Follow-up ranged from 6 months to 6.2 years (median 2.5 years), with 20% of patients having follow-up data at 4 years.

Complete revascularization was associated with a significant reduction in the primary endpoint compared with culprit-only revascularization at 4 years (adjusted hazard ratio [aHR] 0.78; 95% confidence interval [CI] 0.63–0.96; p=0.005). At the longest follow-up, the difference between the groups was not significant (aHR 0.83; 95% CI 0.69–1.01; p=0.063).

At the longest follow-up, there was a 24% reduction in cardiovascular death or myocardial infarction with complete vs. culprit-only revascularization (aHR 0.76; 95% CI 0.58–0.99; p=0.046). There was no difference between the two groups for all-cause mortality (aHR 1.03; 95% CI 0.80–1.32; p=0.818), cardiovascular death (aHR 0.79; 95% CI 0.56–1.02; p=0.184), or non-cardiovascular death (aHR 1.40; 95% CI 0.97–2.02; p=0.115). Ischemia-driven revascularization was significantly reduced in the complete vs. culprit-only group (HR 0.52; 95% CI 0.34–0.85; p=0.002). There were no significant differences between the groups in the safety endpoints of stroke, stent thrombosis, major bleeding, or contrast-associated acute kidney injury.

“At least in the first 4 years, complete revascularization improved outcomes in older patients with STEMI and multivessel disease. A limitation is the lack of patients followed up beyond 4 years and we await additional data from the FIRE trial to provide further information on longer-term outcomes,” concluded Professor Campo.