Key result
Complete revascularization fails to reduce major events versus culprit-only PCI in STEMI patients ≥75 years.
Why the study?
The long-term benefit of complete revascularization after primary PCI in older patients with STEMI and multivessel disease remains uncertain.
Does fractional flow reserve-guided complete revascularization reduce the composite of all-cause mortality, recurrent MI, or any revascularization in older versus younger patients with STEMI and multivessel disease?
RCT (n=627)
Does fractional flow reserve-guided complete revascularization reduce the composite of all-cause mortality, recurrent MI, or any revascularization in older versus younger patients with STEMI and multivessel disease?
Hazard Ratio: 1.29 (95% CI 0.82–2.03)
p-value: p=0.27
FFR-guided complete revascularization provides long-term benefits in STEMI patients under 75 years old, primarily by reducing repeat revascularization, but evidence remains inconclusive for patients 75 and older due to small sample size.
AIMS: The benefit of complete revascularization after primary percutaneous coronary intervention (PCI) is well established in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease, but the long-term effect in older patients remains uncertain. We aimed to evaluate the 10-year outcome of complete revascularization in older patients (aged ≥75 years) compared with younger patients. METHODS AND RESULTS: Patients with STEMI and multivessel disease were randomized to either culprit-only or fractional flow reserve-guided complete revascularization in the DANAMI-3-PRIMULTI trial. This long-term sub-study stratified the included 627 patients by <75 years (517) and ≥75 years (110). The primary outcome was a composite of all-cause mortality, recurrent myocardial infarction, or any revascularization occurring during a median follow-up of 10.5 years. Of the older patients, 50 underwent complete and 60 culprit-only revascularization, and of the younger patients, 264 were completely revascularized compared to 253 who had culprit-only PCI performed.In the older group, complete revascularization showed no association with the primary outcome (adjusted hazard ratio [HR] 1.29, 95% confidence interval [CI]: 0.82-2.03, P = 0.27). In contrast, complete revascularization was associated with a lower risk of the primary outcome (adjusted HR 0.68, 95% CI: 0.53-0.88, P = 0.003) in younger patients, primarily driven by a reduction in any revascularization (adjusted HR 0.60, 95% CI: 0.44-0.83, P = 0.002. CONCLUSION: In patients aged ≥75 years, clear evidence of a long-term (10 years) benefit of complete revascularization was not demonstrated. However, the elderly subgroup was small with limited events, and the finding should be interpreted as inconclusive. In contrast, complete revascularization was associated with a 32% lower risk of adverse outcomes among younger patients, primarily driven by a reduction in repeat revascularization, without evidence of reduced all-cause death or recurrent myocardial infarction.
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Zhou et al. (2026) conducted an RCT in ST-segment elevation myocardial infarction and multivessel disease (n=627). Fractional flow reserve-guided complete revascularization vs. Culprit-only revascularization was evaluated on Composite of all-cause mortality, recurrent myocardial infarction, or any revascularization (HR 1.29, 95% CI 0.82-2.03, p=0.27). Complete revascularization in STEMI patients ≥75 years did not reduce death, recurrent MI, or revascularization versus culprit-only PCI (HR 1.29; 95% CI 0.82-2.03; P=0.27).
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