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Unsolved Questions in the Revascularization of Older Myocardial Infarction Patients with Multivessel Disease
Rita Pavasini1, Federico Sanguettoli1, Luca Zanarelli1
1UO Cardiologia, Azienda Ospedaliero Universitaria di Ferrara, 44124 Ferrara, Italy.
Insights
Elderly patients with myocardial infarction and multivessel coronary artery disease face higher mortality and complications. This review highlights the lack of randomized trials guiding revascularization strategies for older adults with MI.
Area of Science:
- Cardiology
- Geriatric Medicine
- Interventional Cardiology
Background:
- Population aging presents challenges in cardiology, including complex coronary lesions in older adults.
- Elderly patients with myocardial infarction (MI) and multivessel coronary artery disease (CAD) are often frail and comorbid.
- Randomized clinical trials (RCTs) underrepresent elderly patients, necessitating a review of current knowledge.
Purpose of the Study:
- To systematically review current knowledge on revascularization strategies for elderly patients (≥75 years) experiencing myocardial infarction with multivessel coronary artery disease.
- To identify knowledge gaps and guide future research in this understudied population.
Main Methods:
- A systematic review was conducted following PRISMA guidelines.
- Searches were performed on PubMed, Cochrane Library, Google Scholar, and Biomed Central databases (January-February 2022).
- Included studies focused on patients ≥75 years hospitalized for MI with multivessel disease; 36 studies were selected.
Main Results:
- Multivessel CAD affects 50-60% of older MI patients, with double the in-hospital mortality compared to younger counterparts.
- Common complications post-revascularization include bleeding and renal failure.
- For ST-elevation MI (STEMI), primary percutaneous coronary intervention is preferred over fibrinolysis, but optimal revascularization extent remains unclear. For non-STEMI (NSTEMI), invasive or conservative strategies are options, with limited comparative data.
Conclusions:
- This systematic review reveals a significant lack of randomized clinical trials to guide revascularization strategies in elderly patients with STEMI or NSTEMI.
- Further research, including ongoing trials, is crucial to establish evidence-based guidelines for this vulnerable population.
Background:
In cardiology, the global phenomenon of population ageing poses new major challenges, ranging from more comorbid and frail patients to the presence of complex, calcified and multiple coronary lesions. Considering that elderly patients are under-represented in randomized clinical trials (RCT), the aim of this systematic review is to summarize the current knowledge on the revascularization of the elderly patient with myocardial infarction and multivessel coronary artery disease.
Methods:
A systematic review following PRISMA guidelines has been performed. The search was conducted on Pubmed (Medline), Cochrane library, Google Scholar and Biomed Central databases between January and February 2022. We selected the articles focusing on patients hospitalized for myocardial infarction (MI) with multivessel disease and aged 75 years or older. A total of 36 studies have been included.
Results:
Multivessel coronary artery disease is present in around 50-60% of older patients with MI. The in-hospital mortality rate of patients older than 75 years is double compared to their younger counterpart, and the most prevalent complications after revascularization are bleeding and renal failure. In the treatment of patients with ST elevation MI (STEMI), primary percutaneous coronary intervention should be the first choice over fibrinolysis. However, it is not clear whether this population would benefit from complete revascularization or not. In patients with non-ST elevation MI (NSTEMI), an invasive approach with either percutaneous coronary intervention or coronary artery bypass graft may be chosen, but a conservative strategy is also accepted. There are no data from large trials about the comparison of possible revascularization strategies in NSTEMI patients.
Conclusions:
This systematic review shows that this field of research lacks randomized clinical trials to guide revascularization strategy in older STEMI or NSTEMI patients with MI. New results are expected from ongoing trials.
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