Dr. Serkan Bulgurluoğlu

Name of the Study: Complete vs. Culprit-Only Revascularization in Older Patients with ST-segment Elevation Myocardial Infarction: An Individual Patient Meta-Analysis (EARTH-STEMI)

Published in Congress: ESC 2024

Link: https://doi.org/10.1161/CIRCULATIONAHA.124.071493

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Background:

Complete revascularization is the standard of care for patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease. The Functional Assessment in Elderly MI Patients with Multivessel Disease (FIRE) trial demonstrated the benefit of complete revascularization in an elderly cohort; however, the follow-up was limited to 1 year. As a result, the long-term (>1-year) efficacy of this approach in older patients remains a topic of debate. To address this issue, an individual patient data meta-analysis was conducted in STEMI patients aged 75 years or older enrolled in randomized clinical trials comparing complete revascularization with culprit-only revascularization strategies

Objective:

In the EARTH-MI study, long-term (>1 year) complete revascularization was compared with culprit-only revascularization in patients with ST-segment elevation myocardial infarction (STEMI).

Methods:

PubMed, Embase, and the Cochrane database, were systematically searched to identify randomized clinical trials comparing complete vs. culprit-only revascularization. Individual patient-level data were collected from the relevant trials. The primary endpoint was death, myocardial infarction (MI), or ischemia-driven revascularization. The secondary endpoint was cardiovascular death or myocardial infarction.

Results:

Data from seven RCTs, encompassing 1733 patients (917 randomized to culprit-only and 816 to complete revascularization), were analyzed. The median age was 79 [77-83] years. Females were 595 (34%). Follow-up ranged from a minimum of six months to a maximum of 6.2 years (median 2.5 [1-3.8] years). Complete revascularization reduced the primary endpoint up to four years (HR 0.78, 95%CI 0.63-0.96), but not at the longest available follow-up (HR 0.83, 95%CI 0.69-1.01). Complete revascularization significantly reduced the occurrence of cardiovascular death or MI at the longest available follow-up (HR 0.76, 95% CI 0.58-0.99). This was observed even when censoring the follow-up at each year. Long-term rate of death did not differ between complete and culprit-only revascularization arms.

Conclusion:

In this individual patient data meta-analysis of elderly STEMI patients with multivessel coronary artery disease, complete revascularization was associated with a reduction in the primary endpoint of death, myocardial infarction (MI), or ischemia-driven revascularization over a follow-up period of up to 4 years. At the longest follow-up, complete revascularization reduced the composite outcome of cardiovascular death or MI, but did not significantly affect the primary endpoint.