Immediate Complete Revascularization During Index Admission in Older Patients With ST-Segment Elevation Myocardial Infarction

BACKGROUND: Whether age affects the comparative treatment effect of immediate complete revascularization (CR) vs staged CR during the index admission in patients with ST-segment elevation myocardial infarction and multivessel disease remains unknown. OBJECTIVES: This study aimed to assess how age influences clinical outcomes in patients with with ST-segment elevation myocardial infarction and multivessel disease randomized to immediate or in-hospital staged CR. METHODS: This is a secondary analysis of 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, which included 994 patients randomized to immediate or in-hospital staged CR. The primary endpoint at 1 year, defined as a composite of all-cause death, nonfatal myocardial infarction, or any unplanned revascularization, was analyzed according to age and CR strategy. RESULTS: A significant interaction was found between age, as a continuous variable, and CR strategy for the primary endpoint (interaction P = 0.015). The HR for the primary endpoint was initially higher in the staged CR arm until approximately 67 years, after which it increased steadily in the immediate CR arm. In the binary analysis, a significantly higher incidence of the primary endpoint was observed in the immediate CR arm compared with the staged CR arm in patients ≥70 years (45 of 202 [22.3%] vs 29 of 210 [13.8%]; HR: 1.68; 95% CI: 1.06-2.69; log-rank P = 0.029), but not in patients <70 years (20 of 296 [6.8%] vs 24 of 286 [8.4%]; HR: 0.80; 95% CI: 0.45-1.45; log-rank P = 0.470) (multiplicative interaction P = 0.054; relative excess risk due to interaction P = 0.016). CONCLUSIONS: This post hoc analysis of the OPTION-STEMI trial demonstrates that older patients experience significantly worse clinical outcomes with immediate CR than with in-hospital staged CR. These findings suggest that age modifies the treatment effect of the CR strategy and warrant confirmation in adequately powered trials (Timing of FFR-guided PCI for Non-IRA in STEMI and MVD [OPTION-STEMI]; NCT04626882).