Complete versus culprit‐only strategy in older MI patients with multivessel disease. Issue 4 (16th February 2022) - Biscaglia, Simone
Abstract: Aims: The revascularization strategy to pursue in older myocardial infarction (MI) patients with multivessel disease (MVD) is currently unknown. For this reason, while waiting for the results of dedicated trials, we sought to compare a complete versus a culprit‐only strategy in older MI patients by merging data from four registries. Methods and results: The inclusion criteria for the target population of the present study were (i) age ≥ 75 years; (ii) MI (STE or NSTE); (iii) MVD; (iv) successful treatment of culprit lesion. Propensity scores (PS) were derived using logistic regression (backward stepwise selection, p < 0.2). The primary outcome was all‐cause mortality. Secondary outcomes were cardiovascular (CV) death, MI, and major bleeding. Multivariable adjustment included the PS and inverse probability of treatment weighting (IPTW). The Kaplan–Meier plots were weighted for IPT. Among 2087 patients included, 1362 (65%) received culprit‐only treatment whereas 725 (35%) complete revascularization. The mean age was 81.5 years, while the mean follow‐up was 419 ± 284 days. Seventy‐four patients (10%) died in the complete group and 223 in the culprit‐only one (16%). The adjusted cumulative 1‐year mortality was 9.7% in the complete and 12.9% in the culprit‐only group (adjusted HR: 0.67, 95% CI: 0.50–0.89). Complete revascularization was associated with lower incidence of CV death (adjusted HR: 0.68, 95% CI: 0.48–0.95) and MI (adjusted HR 0.67, 95% CI: 0.48–0.95). Conclusions: Culprit‐only is the default strategy in older MI patients with MVD. In our analysis, complete revascularization was associated with lower all‐cause and CV mortality and with a lower MI rate. Key messages: What is already known about this subject? Complete revascularization reduces the occurrence of cardiovascular (CV) death and myocardial infarction (MI) in younger patients with myocardial infarction and multivessel disease. Preliminary data shows that the same strategy could not provide the same benefit in older patients. What does this study add? After multiple strategies aimed at controlling confounders, a complete revascularization strategy was still associated with lower all‐cause and CV mortality as well as with a lower MI rate with a good safety profile. How might this impact clinical practice? A complete revascularization strategy should be pursued also in older patients since it is associated with lower mortality. A dedicated ongoing trial has been designed to confirm the findings of the present study.