Multivessel vs. culprit-only percutaneous coronary intervention strategy in older adults with acute myocardial
Claudio Montalto1, Nuccia Morici2, Aung Myat3
1Department of Molecular Medicine, University of Pavia, Pavia, Italy; Interventional Cardiology Unit, De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy.
Insights
For older adults with multivessel coronary artery disease (MVCAD) and acute myocardial infarction (AMI), multi-vessel percutaneous coronary intervention (MV-PCI) improves survival. This strategy reduces the risk of death and Net Adverse Clinical Events (NACE) compared to culprit-vessel PCI.
Area of Science:
- Cardiology
- Interventional Cardiology
- Geriatric Medicine
Background:
- Optimal revascularization strategy for senior patients with acute myocardial infarction (AMI) and multivessel coronary artery disease (MVCAD) is uncertain.
- This study compares culprit-vessel (CV) PCI versus multi-vessel (MV) PCI in older adults (≥75 years) with AMI.
Purpose of the Study:
- To compare the efficacy of MV-PCI versus CV-PCI in older adults with AMI and MVCAD.
- To evaluate the impact of revascularization strategies on mortality and Net Adverse Clinical Events (NACE).
Main Methods:
- Analysis of four randomized controlled trials involving older adults with AMI.
- Primary endpoint: all-cause death. Secondary endpoint: composite of death, myocardial infarction, stroke, and major bleeding (NACE).
- Propensity score matching and multivariable analysis were used to control for bias.
Main Results:
- 1,334 patients were included; 57.7% received CV-PCI and 42.3% received MV-PCI.
- MV-PCI was associated with significantly lower rates of death (6.0% vs. 9.9%; p=0.01) and NACE (11.2% vs. 15.5%; p=0.016) at 365-day follow-up.
- Multivariable and propensity analyses confirmed MV-PCI independently reduced the hazard of death (HR: 0.65) and NACE (HR: 0.72).
Conclusions:
- In older adults with AMI and MVCAD managed invasively, MV-PCI is linked to improved survival and reduced NACE compared to CV-PCI.
- The findings were consistent across age subgroups and bias considerations.
- Further adequately sized randomized controlled trials (RCTs) are needed to confirm these results.
Background:
The optima revascularization strategy for senior patients admitted with acute myocardial infarction (AMI) in the context of multivessel coronary artery disease (MVCAD) remains unclear. We aimed to compare a strategy of culprit-vessel (CV) vs. multi-vessel percutaneous coronary intervention (MV-PCI) in older adults (≥75 years) with AMI.
Methods:
We analyzed four randomized controlled trials designed to include older adults with AMI. The primary endpoint was all-cause death. The secondary endpoint was the composite of all-cause death, myocardial infarction, stroke and major bleeding (Net Adverse Clinical Events, NACE). A non-parsimonious propensity score and nearest-neighbor matching was performed to account for bias.
Results:
A total of 1,334 trial participants were included; of them, 770 (57.7%) underwent CV-PCI and 564 (42.3%) a MV-PCI strategy. After a median follow-up of 365 days, patients treated with MV-PCI experienced a lower rate of death (6.0% vs. 9.9%; p = 0.01) and of NACE (11.2% vs. 15.5%; p = 0.016). After multivariable analysis, MV-PCI was independently associated with a lower hazard of death (hazard ratio [HR]: 0.65; 95% confidence interval [CI]: 0.42-0.96; p = 0.03) and NACE (NACE 0.72[0.53-0.98]; p = 0.04). These results were confirmed in a matched propensity analysis, were consistent throughout the spectrum of older age and when analyzed by subgroups and when immortal-time bias was considered.
Conclusions:
In the setting of older adults with MVCAD who were managed invasively for AMI, a MV-PCI strategy to pursue complete revascularization was associated with better survival and lower risk of NACE compared to a CV-PCI. Adequately sized RCTs are required to confirm these findings.
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