In older patients with myocardial infarction, does complete revascularization lead to better clinical outcomes than intervention of the culprit lesion only?
Patients 75 years or older with either ST-elevation or non-ST elevation MI have improved clinically important outcomes with complete, rather than culprit lesion-only, revascularization. This finding is similar to the findings in younger patients.
Randomized controlled trial (nonblinded)
Industry + foundation
Inpatient (any location) with outpatient follow-up
In this multicenter study from Europe, investigators enrolled patients 75 years or older who were hospitalized with either ST-elevation or non-ST-elevation myocardial infarction (MI) and had undergone successful percutaneous coronary intervention (PCI) of a culprit lesion and had evidence of multivessel disease. Patients were randomized within 48 hours to receive complete revascularization with PCI of all functionally significant nonculprit lesions based on physiologic guidance (n = 720) or to no further revascularization (n = 725). The 2 groups were balanced at baseline: median age was 80 years, 37% were women, and 35% were admitted for ST-elevation MI. There was a decreased incidence of the primary outcome (a composite of death, MI, stroke, or ischemia-driven revascularization within one year) in the complete revascularization group with a number needed to treat (NNT) of 19 (15.7% vs 21.0%; hazard ratio [HR] 0.73; 95% CI 0.57 - 0.93; P = .01). This group also had a reduction in secondary outcomes including the composite of cardiovascular death or MI at 1 year (HR 0.64; 0.47 - 0.88; NNT = 22), and death from any cause (HR 0.70; 0.51 - 0.96; NNT = 27). There was no significant difference detected in the composite safety outcome of contrast-induced acute kidney injury, stroke, or bleeding. Note: Although many of the outcomes were objective, knowledge of the angiographic results may have led to a bias toward subsequent revascularization in the culprit-only group in this nonmasked study.
Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine