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Complete revascularization timing in ST-segment elevation myocardial infarction and multivessel disease with heart
Min Chul Kim1, Joon Ho Ahn1, Dae Young Hyun1
1Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, 42 Jebong-ro, Dong-gu, Gwangju 61469, South Korea.
Insights
Immediate complete revascularization in ST-segment elevation myocardial infarction (STEMI) patients with heart failure showed worse outcomes. Staged revascularization appears safer for STEMI patients with heart failure and multivessel disease.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Optimal timing for complete revascularization in ST-segment elevation myocardial infarction (STEMI) with multivessel disease and heart failure is unclear.
- The OPTION-STEMI trial investigated immediate versus staged complete revascularization during index admission.
Purpose of the Study:
- To compare immediate vs. staged complete revascularization in STEMI patients with multivessel disease.
- To analyze the impact of heart failure (Killip class II or III) on outcomes after revascularization strategies.
Main Methods:
- Randomized controlled trial (OPTION-STEMI) comparing immediate vs. staged complete revascularization.
- Primary endpoint: composite of death, myocardial infarction, or unplanned revascularization at 1 year.
- Subgroup analysis based on heart failure status at admission.
Main Results:
- Immediate complete revascularization was not non-inferior to staged revascularization overall.
- Patients with heart failure (33.1%) had higher primary endpoint rates (18.2% vs 8.7%).
- In heart failure patients, immediate revascularization showed higher adverse events (22.8% vs 13.3%; HR 1.79), unlike in non-heart failure patients (8.0% vs 9.5%; HR 0.84).
Conclusions:
- Immediate complete revascularization is not superior to staged revascularization in STEMI patients without cardiogenic shock.
- Worse outcomes with immediate revascularization appear limited to patients with heart failure at admission.
- Further research is needed to confirm non-inferiority of immediate revascularization in patients without heart failure.
Background And Aims:
The optimal timing of complete revascularization in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease complicated by heart failure remains uncertain.
Methods:
The OPTION-STEMI (Optimal Timing of Fractional Flow Reserve-Guided Complete Revascularization for Non-Infarct-Related Artery in ST-segment Elevation Myocardial Infarction with Multivessel Disease) trial compared immediate vs staged complete revascularization during the index admission in patients with STEMI and multivessel disease. In the OPTION-STEMI trial, immediate complete revascularization was not found to be non-inferior for the primary endpoint compared with staged complete revascularization. Pre-specified subgroup analysis was performed according to heart failure at admission, defined as Killip class II or III. The primary endpoint was a composite of death from any cause, non-fatal myocardial infarction, or any unplanned revascularization at 1 year.
Results:
Among 994 randomized patients, 329 (33.1%) had heart failure at admission. These patients had a higher risk of primary endpoint than those without heart failure (18.2% vs 8.7%; adjusted HR 1.63; 95% CI 1.11-2.40; P = .013). At 1 year, immediate complete revascularization was associated with a higher incidence of the primary endpoint than staged complete revascularization in patients with heart failure (22.8% vs 13.3%; HR 1.79; 95% CI 1.05-3.04), but not in those without heart failure (8.0% vs 9.5%; HR 0.84; 95% CI .50-1.40). A significant interaction was observed between heart failure status and randomized strategy (P = .043).
Conclusions:
In the OPTION-STEMI trial, among patients with STEMI and multi-vessel disease who were not in cardiogenic shock, immediate complete revascularization was not non-inferior compared with staged complete revascularization. However, subgroup analysis suggests that the worse outcomes with immediate complete revascularization may be limited to patients with heart failure at admission. Further studies are required to demonstrate the non-inferiority of immediate complete revascularization compared with staged complete revascularization in patients without heart failure.
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