Key result
FFR-guided complete revascularization reduced the 10-year primary composite outcome in patients <75 years (HR 0.68, P=0.003), but showed no benefit in those ≥75 years (HR 1.29, P=0.27).
Why the study?
The benefit of complete revascularization after primary PCI is well established in patients with STEMI and multivessel disease, but its long-term effect in older patients aged ≥75 years remains uncertain.
Does fractional flow reserve-guided complete revascularization reduce the 10-year composite of all-cause mortality, recurrent myocardial infarction, or any revascularization in older (≥75 years) versus younger (<75 years) patients with STEMI and multivessel disease?
RCT (n=627)
Randomized (1:1 to culprit-only or FFR-guided complete revascularization, stratified by age in this sub-study)
Does fractional flow reserve-guided complete revascularization reduce the 10-year composite of all-cause mortality, recurrent myocardial infarction, or any revascularization in older (≥75 years) versus younger (<75 years) patients with STEMI and multivessel disease?
Over a 10.5-year follow-up, FFR-guided complete revascularization in STEMI with multivessel disease significantly reduced adverse cardiovascular outcomes (primarily repeat revascularization) in patients younger than 75 years, but demonstrated no benefit in patients aged 75 years or older.
Supports culprit-only PCI in patients ≥75 years; challenges uniform complete revascularization recommendations in multivessel STEMI.
Background 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. Purpose We aimed to evaluate the 10-year outcome of complete revascularization in older patients (aged ≥75 years) compared with younger patients. Methods 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 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. Results Of the older patients, 50 underwent complete and 60 culprit-only revascularization. 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). Conclusions In patients aged ≥75 years, evidence of a 10-years benefit of complete revascularization was not found. Complete revascularization was associated with a 32% lower risk of adverse outcomes among younger patients, primarily driven by a reduction in repeat revascularization.Abstract illustration
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Zhou et al. (2026) conducted an RCT in ST-segment elevation myocardial infarction (STEMI) and multivessel disease (n=627). Fractional flow reserve-guided complete revascularization vs. Culprit-only percutaneous coronary intervention (PCI) 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). FFR-guided complete revascularization reduced the 10-year primary composite outcome in patients <75 years (HR 0.68, P=0.003), but showed no benefit in those ≥75 years (HR 1.29, P=0.27).
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