Key result
Immediate complete revascularization compared with staged revascularization resulted in a MACE rate of 11.6% vs 7.5% at 1 year (HR 1.60; 95% CI 0.65-3.91) in patients with STEMI and MVD.
Why the study?
The optimal timing of complete revascularization in primary PCI for patients with STEMI and multivessel disease remained unclear.
Does immediate complete revascularization reduce MACE compared to staged complete revascularization in patients with STEMI and multivessel disease?
RCT (n=248)
Yes
Does immediate complete revascularization reduce MACE compared to staged complete revascularization in patients with STEMI and multivessel disease?
Hazard Ratio: 1.6 (95% CI 0.65–3.91)
Absolute Event Rate: 11.6% vs 7.5%
In a prematurely terminated and underpowered trial of STEMI patients with multivessel disease, there was no significant difference in MACE between immediate and staged complete revascularization.
Immediate revascularization shows no MACE benefit over staged; underpowered RCT leaves optimal timing unresolved.
BACKGROUND: We aimed to compare clinical outcomes between immediate and staged complete revascularization in primary percutaneous coronary intervention (PCI) for treating ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD). METHODS: A total of 248 patients were enrolled in a prospective, randomized, and multicenter registry. Immediate revascularization was defined as one-time PCI of culprit and non-culprit lesions at the initial procedure. Staged revascularization was defined as PCI of non-culprit lesions at a later date (mean, 4.4 days; interquartile range, 1-11.4), following initial culprit revascularization. The end points were major adverse cardiovascular events (MACE; composite of total death, recurrent myocardial infarction, and revascularization), any individual components of MACE, cardiac death, stent thrombosis, and stroke at 12 months. RESULTS: During a follow-up of 1 year, MACE occurred in 12 patients (11.6%) in the immediate revascularization group and in 8 patients (7.5%) in staged revascularization group (hazard ratio [HR] 1.60, 95% confidence interval [CI] 0.65-3.91). The incidence of total death was numerically higher in the immediate group than in the staged group (9.7% vs 2.8%, HR 3.53, 95% CI 0.97-12.84); There were no significant differences between the 2 groups in risks of any individual component of MACE, cardiac death, stroke, and in-hospital complications, such as need for transfusion, bleeding, acute renal failure, and acute heart failure. This study was prematurely terminated due to halt of production of everolimus-eluting stents (manufactured as PROMUS Element by Boston Scientific, Natick, Massachusetts). CONCLUSIONS: Due to its limited power, no definite conclusion can be drawn regarding complete revascularization strategy from the present study. Further large randomized clinical trials would be warranted to confirm optimal timing of complete revascularization for patients with STEMI and MVD.
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Park et al. (2023) conducted an RCT in ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) (n=248). Immediate complete revascularization vs. Staged complete revascularization was evaluated on Major adverse cardiovascular events (MACE; composite of total death, recurrent myocardial infarction, and revascularization) at 12 months (HR 1.60, 95% CI 0.65-3.91). Immediate complete revascularization compared with staged revascularization resulted in a MACE rate of 11.6% vs 7.5% at 1 year (HR 1.60; 95% CI 0.65-3.91) in patients with STEMI and MVD.
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