Complete revascularization versus culprit-only revascularization in older adults with ST-elevation myocardial
Dae Yong Park1, Jiun-Ruey Hu2, Jennifer Frampton1
1Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA.
Insights
Complete revascularization (CR) in older adults with ST-elevation myocardial infarction (STEMI) reduces major adverse cardiovascular events (MACE) compared to culprit-only revascularization (COR). This approach did not increase bleeding or kidney injury risks, aiding clinical decisions.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Geriatric Cardiology
Background:
- Complete revascularization (CR) is recommended for ST-elevation myocardial infarction (STEMI) but its benefit in older adults is uncertain.
- Older adults have higher risks for bleeding and comorbidities, complicating revascularization decisions.
- This meta-analysis incorporates recent trials, including the FIRE trial and COMPLETE subgroup analysis, focusing on adults aged ≥75 years.
Purpose of the Study:
- To evaluate the efficacy and safety of complete revascularization (CR) versus culprit-only revascularization (COR) in older adults with STEMI.
- To synthesize evidence from randomized controlled trials (RCTs) to inform clinical practice for this vulnerable population.
Main Methods:
- A meta-analysis of 5 RCTs including 3513 older adults (defined as age >65 or >75 years) with STEMI.
- Literature search conducted up to October 21, 2023.
- Primary outcome: major adverse cardiovascular events (MACE). Secondary outcomes: major bleeding and contrast-associated acute kidney injury (CA-AKI). Integrated hazard ratios (HRs) calculated using random-effects models.
Main Results:
- CR was associated with a significantly lower hazard of MACE compared to COR (HR 0.60, p=0.047).
- This benefit was observed in trials defining older adults as age >65 but not consistently in those defining them as age >75.
- No significant difference in the hazard of major bleeding or CA-AKI was found between CR and COR.
Conclusions:
- In older adults with STEMI, CR reduces MACE without increasing major bleeding or CA-AKI compared to COR.
- These findings support CR in older STEMI patients, aiding shared decision-making between clinicians, patients, and caregivers.
- Further research may be needed to refine the definition of 'older adults' for optimal CR benefit stratification.
Background:
Randomized controlled trials (RCTs) of complete revascularization (CR) versus culprit-only revascularization (COR) in patients with ST-elevation myocardial infarction (STEMI) have shifted the recommendation for CR from class III to class I in the AHA/ACC/SCAI guidelines, but it remains unclear if the benefit of CR over COR extends to older adults, who have greater bleeding risk, comorbidity burden, and complexity of lesions. We performed a meta-analysis to place the results of the previous RCTs in the context of the recently published FIRE trial and the subgroup analysis of the COMPLETE trial in adults ≥75 years old.
Methods:
We searched the literature from inception to October 21, 2023. RCTs of CR versus COR in STEMI were selected if it reported results for older adults, defined as either age > 65 years or > 75 years. Integrated hazard ratios (HRs) were calculated using random effects models. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes were major bleeding and contrast-associated acute kidney injury (CA-AKI).
Results:
In this meta-analysis of 5 RCTs including 3513 older adults, CR was associated with a lower hazard of MACE than COR (HR 0.60, 95% CI 0.37-0.99, p = 0.047). Sensitivity analysis including trials that defined older adults as age > 65 years resulted in a lower hazard of MACE with CR versus COR, but not in trials that defined older adults as age > 75 years. There was no difference in the hazard of major bleeding or CA-AKI between CR and COR.
Conclusions:
In this largest meta-analysis to date investigating CR compared with COR in older adults with STEMI, CR was associated with reduced MACE without a concomitant increase in major bleeding or CA-AKI compared with COR. These results can help cardiologists and geriatricians involved in shared decision-making with patients and caregivers when contemplating whether to pursue CR in older adults.
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