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The benefit of complete revascularization after primary PCI for STEMI is attenuated by increasing age: Results from
Francis R Joshi1, Jacob Lønborg1, Golnaz Sadjadieh1
1Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
Insights
For older adults (≥75 years) with ST-elevation myocardial infarction (STEMI), complete revascularization offers no significant benefit over culprit-only treatment. A symptom-guided approach to further invasive treatment is recommended for elderly STEMI patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Geriatric Cardiology
Background:
- Increasing numbers of older patients are undergoing Primary Percutaneous Coronary Intervention (PPCI) for ST-elevation myocardial infarction (STEMI).
- Optimal management of non-culprit lesions in elderly STEMI patients remains unclear.
Purpose of the Study:
- To evaluate the impact of age on outcomes following culprit-only versus complete revascularization in STEMI patients treated with PPCI.
- To determine if complete revascularization provides a prognostic advantage in elderly patients (≥75 years).
Main Methods:
- Analysis of patients aged ≥75 years from the DANAMI-3-PRIMULTI study.
- Randomization to either culprit-only or complete Fractional Flow Reserve (FFR)-guided revascularization.
- Primary endpoint: composite of all-cause mortality, nonfatal reinfarction, and ischemia-driven revascularization at 27 months.
Main Results:
- Elderly patients (≥75 years) were more likely female, hypertensive, with lower hemoglobin and higher creatinine levels.
- No significant difference in the primary endpoint between culprit-only and complete revascularization in patients ≥75 years (HR 1.49, p=0.19).
- Significant interaction between age, treatment, and outcome (p<0.001), suggesting no benefit of complete revascularization beyond age 75.
Conclusions:
- In STEMI patients ≥75 years, prophylactic complete revascularization of non-culprit lesions does not offer a significant prognostic benefit after culprit lesion treatment.
- Current data support a symptom-guided strategy for further invasive treatment in elderly STEMI patients.
- Further research is needed to fully elucidate optimal revascularization strategies in this demographic.
Objectives:
To ascertain the effect of age on outcomes after culprit-only and complete revascularization after Primary PCI (PPCI) for ST-elevation myocardial infarction (STEMI).
Background:
The numbers of older patients being treated with PPCI are increasing. The optimal management of nonculprit stenoses in such patients is unclear.
Methods:
We conducted an analysis of patients aged ≥75 years randomized in the DANAMI-3-PRIMULTI study to either culprit-only or complete FFR-guided revascularization. The primary endpoint was a composite of all-cause mortality, nonfatal reinfarction, and ischaemia-driven revascularization of lesions in noninfarct-related arteries after a median of 27 months of follow-up.
Results:
One hundred and ten of six hundred and twenty seven patients in the DANAMI-3-PRIMULTI trial were aged ≥75 years. These patients were more likely female (p < .001), hypertensive (p < .001), had lower hemoglobin levels (p < .001), and higher serum creatinine levels (p < .001) than the younger patients in the trial. Other than less use of drug-eluting stents (96.6 versus 88.0%: p = .02), there were no significant differences in procedural technique and success between patients aged <75 years and those ≥75 years of age. There was no significant difference in the incidence of the primary endpoint in patients ≥75 years randomized to culprit-only or FFR-guided complete revascularization (HR 1.49 [95% CI 0.57-4.65]; log-rank p = .19; p for interaction versus patients <75 years <.001). There was a significant interaction between age as a continuous variable, treatment assignment, and the primary outcome (p < .001); beyond the age of about 75 years, there may be no prognostic advantage to complete revascularization.
Conclusions:
In patients ≥75 years, after treatment of the culprit lesion in STEMI, there is no significant prognostic benefit to prophylactic complete revascularization of nonculprit stenoses. Pending further study, data would support a symptom-guided approach to further invasive treatment.
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