The benefit of complete revascularization after primary PCI for STEMI is attenuated by increasing age: Results from the DANAMI‐3‐PRIMULTI randomized study

Francis R. Joshi; Jacob Lønborg; Golnaz Sadjadieh; Steffen Helqvist; Lene Holmvang; Rikke Sørensen; Erik Jørgensen; Frants Pedersen; Hans Henrik Tilsted; Dan Eik Høfsten; Lars Køber; Henning Kelbæk; Thomas Engstrøm

doi:10.1002/ccd.29131

July 18, 2020Catheterization and Cardiovascular Interventions

The benefit of complete revascularization after primary PCI for STEMI is attenuated by increasing age: Results from the DANAMI‐3‐PRIMULTI randomized study

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Why the study?

The number of older patients treated with primary PCI for STEMI is increasing, but the optimal management of nonculprit stenoses in these patients remains unclear.

Does FFR-guided complete revascularization reduce the composite of mortality, reinfarction, and ischaemia-driven revascularization compared to culprit-only revascularization in STEMI patients aged ≥75 years?

Structured PICO

Does FFR-guided complete revascularization reduce the composite of mortality, reinfarction, and ischaemia-driven revascularization compared to culprit-only revascularization in STEMI patients aged ≥75 years?

P

Population

110 patients aged ≥75 years with ST-elevation myocardial infarction (STEMI) undergoing primary PCI (subgroup from the 627-patient DANAMI-3-PRIMULTI trial)

I

Intervention

FFR-guided complete revascularization of nonculprit stenoses

C

Comparator

Culprit-only revascularization

O

Outcome

Composite of all-cause mortality, nonfatal reinfarction, and ischaemia-driven revascularization of lesions in noninfarct-related arteriescomposite

In STEMI patients aged ≥75 years, prophylactic FFR-guided complete revascularization of nonculprit lesions does not provide a prognostic benefit over culprit-only PCI, suggesting a symptom-guided approach may be preferable in older adults.

Implication

No benefit of complete revascularization in STEMI patients ≥75 years; leaves open optimal strategy and requires dedicated elderly trials.

Abstract

OBJECTIVES: To ascertain the effect of age on outcomes after culprit-only and complete revascularization after Primary PCI (PPCI) for ST-elevation myocardial infarction (STEMI). BACKGROUND: The numbers of older patients being treated with PPCI are increasing. The optimal management of nonculprit stenoses in such patients is unclear. METHODS: We conducted an analysis of patients aged ≥75 years randomized in the DANAMI-3-PRIMULTI study to either culprit-only or complete FFR-guided revascularization. The primary endpoint was a composite of all-cause mortality, nonfatal reinfarction, and ischaemia-driven revascularization of lesions in noninfarct-related arteries after a median of 27 months of follow-up. RESULTS: One hundred and ten of six hundred and twenty seven patients in the DANAMI-3-PRIMULTI trial were aged ≥75 years. These patients were more likely female (p < .001), hypertensive (p < .001), had lower hemoglobin levels (p < .001), and higher serum creatinine levels (p < .001) than the younger patients in the trial. Other than less use of drug-eluting stents (96.6 versus 88.0%: p = .02), there were no significant differences in procedural technique and success between patients aged <75 years and those ≥75 years of age. There was no significant difference in the incidence of the primary endpoint in patients ≥75 years randomized to culprit-only or FFR-guided complete revascularization (HR 1.49 [95% CI 0.57-4.65]; log-rank p = .19; p for interaction versus patients <75 years <.001). There was a significant interaction between age as a continuous variable, treatment assignment, and the primary outcome (p < .001); beyond the age of about 75 years, there may be no prognostic advantage to complete revascularization. CONCLUSIONS: In patients ≥75 years, after treatment of the culprit lesion in STEMI, there is no significant prognostic benefit to prophylactic complete revascularization of nonculprit stenoses. Pending further study, data would support a symptom-guided approach to further invasive treatment.