Effects of complete revascularization according to age in patients with ST-segment elevation myocardial infarction
Kevin R Bainey1, David A Wood2, Matthias Bossard3
1Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
Insights
Complete revascularization in ST-segment elevation myocardial infarction (STEMI) benefits all patients, including older adults. This strategy reduces major cardiovascular events compared to treating only the culprit lesion, regardless of age.
Area of Science:
- Cardiology
- Interventional Cardiology
- Geriatric Cardiology
Background:
- ST-segment elevation myocardial infarction (STEMI) management often involves percutaneous coronary intervention (PCI).
- Complete revascularization reduces major cardiovascular events compared to culprit-lesion-only PCI in STEMI.
- The impact of patient age on the benefits of complete revascularization remains unclear.
Purpose of the Study:
- To investigate whether age influences the effectiveness of complete revascularization versus culprit-lesion-only PCI in STEMI patients.
- To analyze treatment effects in patients aged ≥65 years compared to those <65 years.
Main Methods:
- Subgroup analysis of the multinational randomized COMPLETE trial.
- Comparison of complete revascularization versus culprit-lesion-only PCI.
- Evaluation of two coprimary outcomes: cardiovascular death or new myocardial infarction, and cardiovascular death, new myocardial infarction, or ischemia-driven revascularization.
- Stratification by age (≥65 years vs <65 years).
Main Results:
- Older patients (≥65 years) had higher event rates for both coprimary outcomes.
- Complete revascularization reduced the first coprimary outcome in both age groups (≥65 years: HR 0.77; <65 years: HR 0.72).
- Complete revascularization significantly reduced the second coprimary outcome in both age groups (≥65 years: HR 0.56; <65 years: HR 0.48).
- No significant interaction between age and treatment effect was observed for either outcome.
Conclusions:
- Complete revascularization is beneficial for STEMI patients with multivessel coronary artery disease, irrespective of age.
- The strategy of complete revascularization can be safely considered for older adults.
- Age does not negate the benefits of complete revascularization in STEMI management.
Background:
In ST-segment elevation myocardial infarction (STEMI), complete revascularization with percutaneous coronary intervention (PCI) reduces major cardiovascular events compared with culprit-lesion-only PCI. Whether age influences these results remains unknown.
Methods:
COMPLETE was a multinational, randomized trial evaluating a strategy of staged complete revascularization, consisting of angiography-guided PCI of all suitable nonculprit lesions, versus a strategy of culprit-lesion-only PCI. In this prespecified subgroup analysis, treatment effect according to age (≥65 years vs <65 years) was determined for the first coprimary outcome of cardiovascular (CV) death or new myocardial infarction (MI) and the second coprimary outcome of CV death, new MI, or ischemia-driven revascularization (IDR). Median follow-up was 35.8 months (interquartile range [IQR]: 27.6-44.3 months).
Results:
Of 4,041 patients randomized in COMPLETE, 1,613 were aged ≥ 65 years (39.9%). Higher event rates were observed for both coprimary outcomes in patients aged ≥ 65 years comparted with those aged < 65 years (11.2% vs 7.9%, HR 1.49, 95% CI 1.22-1.83; 14.4% vs 11.8%, HR 1.28, 95% CI 1.07-1.52, respectively). Complete revascularization reduced the first coprimary outcome in patients ≥ 65 years (9.7% vs 12.5%, HR 0.77; 95% CI, 0.58-1.04) and < 65 years (6.7% vs 9.1%, HR 0.72; 95% CI, 0.54-0.96)(interaction P = .74). The second coprimary outcome was reduced in those ≥ 65 years (HR 0.56, 95% CI, 0.43-0.74) and < 65 years (HR 0.48, 95% CI, 0.37-0.61 (interaction P = .37). A sensitivity analysis was performed with consistent results demonstrated using a 75-year threshold (albeit attenuated).
Conclusions:
In patients with STEMI and multivessel CAD, complete revascularization compared with culprit-lesion-only PCI reduced major cardiovascular events regardless of patient age and could be considered as a revascularization strategy in older adults.
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