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Complete or Culprit-Only PCI in Older Patients with Myocardial Infarction
Simone Biscaglia1, Vincenzo Guiducci1, Javier Escaned1
1From the Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara (S.B., V. Lodolini, R.P., P.C., C.T., A.E., C.P., G. Campo), the Cardiology Unit, Azienda Unità Sanitaria Locale (USL) IRCCS Reggio Emilia, S. Maria Nuova Hospital, Reggio Emilia (V.G., G.P.), the Cardiology Unit, Ospedale Maggiore (V. Lanzilotti, G. Casella, G.I.), and the Department of Biomedical and Neuromotor Sciences, University of Bologna (E.M.), Bologna, the Cardiovascular Department, Infermi Hospital, Rimini (A.S., M.M.), the Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, Orbassano, and Rivoli Infermi Hospital ASL TO3, Turin (E.C., F.V.), the Cardiology Unit, Umberto I Hospital, ASP Siracusa, Siracusa (G.S.), S.C. Cardiologia, Ospedale Sant'Andrea, ASL5 Liguria, La Spezia (A.M., G. Caretta), the Cardiology Unit, Ospedale Civile di Baggiovara, Baggiovara (M.R.), Interventional Cardiology, Department of Cardio-Thoracic and Vascular Sciences, Ospedale dell'Angelo, Venice (M.B.), the Department of Cardiology, S. Maria delle Croci Hospital, Ravenna (L.F.), the Cardiovascular Department, Azienda USL Toscana Sud-Est, Misericordia Hospital, Grosseto (A.P.), the Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome (G.B.-Z.), and the Cardiology Unit, Ospedale Santa Maria Goretti, Latina (I.C.), Mediterranea Cardiocentro, Naples (G.B.-Z.), Maria Cecilia Hospital, Cotignola (P.C., D.D.), the Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome (E.B.), and the Interventional Cardiology Unit, Presidio Ospedaliero San Salvatore di Pesaro, Pesaro (M.T.) - all in Italy; Hospital Clínico San Carlos, Complutense University of Madrid (J.E.), Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), and Instituto de Investigación Hospital La Paz, University Hospital La Paz (R.M., A.J.-R.), Madrid, CIBERCV, Department of Cardiology, Hospital Clínico Universitario, Valladolid (I.A.S.), and CIBERCV, Cardiology Department, H. Universitario y Politécnico La Fe, Valencia (J.L.D.G.) - all in Spain; and the Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland (D.D.).
Background:
The benefit of complete revascularization in older patients (≥75 years of age) with myocardial infarction and multivessel disease remains unclear.
Methods:
In this multicenter, randomized trial, we assigned older patients with myocardial infarction and multivessel disease who were undergoing percutaneous coronary intervention (PCI) of the culprit lesion to receive either physiology-guided complete revascularization of nonculprit lesions or to receive no further revascularization. Functionally significant nonculprit lesions were identified either by pressure wire or angiography. The primary outcome was a composite of death, myocardial infarction, stroke, or any revascularization at 1 year. The key secondary outcome was a composite of cardiovascular death or myocardial infarction. Safety was assessed as a composite of contrast-associated acute kidney injury, stroke, or bleeding.
Results:
A total of 1445 patients underwent randomization (720 to receive complete revascularization and 725 to receive culprit-only revascularization). The median age of the patients was 80 years (interquartile range, 77 to 84); 528 patients (36.5%) were women, and 509 (35.2%) were admitted for ST-segment elevation myocardial infarction. A primary-outcome event occurred in 113 patients (15.7%) in the complete-revascularization group and in 152 patients (21.0%) in the culprit-only group (hazard ratio, 0.73; 95% confidence interval [CI], 0.57 to 0.93; P = 0.01). Cardiovascular death or myocardial infarction occurred in 64 patients (8.9%) in the complete-revascularization group and in 98 patients (13.5%) in the culprit-only group (hazard ratio, 0.64; 95% CI, 0.47 to 0.88). The safety outcome did not appear to differ between the groups (22.5% vs. 20.4%; P = 0.37).
Conclusions:
Among patients who were 75 years of age or older with myocardial infarction and multivessel disease, those who underwent physiology-guided complete revascularization had a lower risk of a composite of death, myocardial infarction, stroke, or ischemia-driven revascularization at 1 year than those who received culprit-lesion-only PCI. (Funded by Consorzio Futuro in Ricerca and others; FIRE ClinicalTrials.gov number, NCT03772743.).
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