Key Points:
- Approximately 50% of patients with STEMI have multivessel disease but data regarding the benefit of complete versus culprit only revascularization are limited among older adults.
- The EARTH STEMI meta-analysis, pooled individual patient level data from 7 randomized clinical trials, to examine the benefit of complete versus culprit only revascularization among 1,733 older patients (75 years or older) with STEMI and multivessel disease.
- Over 4 years of follow-up, complete revascularization resulted in a reduction in the primary composite endpoint of death, MI, or ischemia-driven revascularization as compared with culprit only revascularization. However, in the setting of a numeric increase in non-cardiovascular deaths and lower available follow-up data, the reduction in the primary endpoint was nullified beyond 4 years.
Clinical trials have demonstrated that complete revascularization reduces the risk of major adverse cardiovascular events among the overall population of patients with STEMI and multivessel disease. However, clinical trial data have primarily been limited to younger adults; elderly adults have been underrepresented. Additional data are therefore needed among elderly adults as they represent an increasing proportion of MI populations, often have higher complication rates from revascularization, and have competing risks of non-cardiovascular events.
The EARTH STEMI meta-analysis was an individual patient level data meta-analysis of 7 randomized clinical trials including COMPLETE, FIRE, FULL-REVASC, DANAMI-3–PRIMULTI, COMPARE ACUTE, and CvLPRIT. and examined the benefit of complete versus culprit only revascularization among 1,733 older patients (75 years or older) with STEMI and multivessel disease. The primary endpoint was death, any MI, or ischemia driven revascularization. The key secondary endpoint was cardiovascular death or MI.
The mean age of the participants was 79 years and 34% were women. The right coronary artery was the culprit vessel in 46% of participants. Radial access was utilized in 76% of participants and among individuals undergoing complete revascularization, 57% were guided by physiology. The median follow up was 2.5 years (1 – 3.8 years). Outcomes beyond 4 years was available in only 20% of participants.
Complete revascularization reduced the risk of the primary composite endpoint of death, MI, and ischemia driven revascularization at 4 years with an adjusted hazard ratio 0.78 (95% CI, 0.63 – 0.96). However, over 6 years follow-up, there was no difference in the primary endpoint with an adjusted hazard ratio of 0.83 (95% CI 0.69 – 1.01) with numerically higher non-cardiovascular deaths in the complete revascularization arm. Over the longest available follow-up period (approximately 6 years), the key secondary endpoint, cardiovascular death or MI, was reduced by complete revascularization (adjusted hazard ratio 0.76 [95% CI, 0.58 – 0.99). No difference in secondary endpoints of death, cardiovascular death, non-cardiovascular death, and MI were observed. However, complete revascularization reduced ischemia-driven revascularization (hazard ratio 0.52 [95% CI, 0.34 – 0.85). There was no difference in safety endpoints of stroke, stent thrombosis, major bleeding, and contrast associated acute kidney injury.
In conclusion, complete revascularization lowered the incidence of ischemic events up to 4 years after STEMI among patients aged 75 years or older with multivessel disease. Complete revascularization did not reduce all-cause mortality. Additional data are needed to clarify whether complete revascularization is beneficial beyond 4 years.