Addressing nonculprit lesions during primary PCI noninferior to staged approach in STEMI
Key takeaways:
- Addressing nonculprit lesions during primary PCI for STEMI was noninferior vs. a staged strategy.
- The trial was powered for noninferiority but the immediate multivessel PCI approach also achieved superiority.
Immediate PCI of nonculprit lesions during index hospitalization for STEMI was shown to be noninferior with fewer adverse events vs. a staged strategy addressing the nonculprit lesions after successful primary PCI, a speaker reported.
The results of the MULTISTARS-AMI trial were presented at the European Society of Cardiology Congress.
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“We all know that patients with acute STEMI frequently present with multivessel coronary artery disease, and previous studies support complete revascularization in these patients. But the optimal timing of revascularization of nonculprit lesions immediately during the index procedure or as a staged procedure remains unknown,” Barbara E. Stähli, MD, MPH, MBA, interventional cardiologist at University Hospital Zurich, Switzerland, said during a press conference. “The primary objective of the MULTISTARS-AMI trial was to investigate whether immediate multivessel PCI is noninferior to staged multivessel PCI performed within 19 to 45 days among hemodynamically stable patients with STEMI and multivessel disease, of course, after successful primary PCI of the culprit artery.”
For this study, researchers enrolled a total of 840 patients with acute STEMI and multivessel CAD and randomly assigned 418 to immediate PCI of nonculprit lesions during the index procedure (mean age, 66 years; 77% men) and 422 to staged PCI of nonculprit lesions within 19 to 45 days after successful primary PCI (mean age, 64 years; 81% men).
Multivessel CAD was defined as the presence of at least one nonculprit coronary artery lesion with 70% or more stenosis on angiography.
The primary endpoint was a composite of all-cause death, nonfatal MI, stroke, unplanned ischemia-driven revascularization or HF hospitalization at 1 year.
Overall, 80.4% to 83.2% of the cohort had one significant nonculprit lesion identified.
Femoral access was used in nearly three-quarters of all procedures and the median hospital stay was 4 days in both treatment groups for their index procedure.
In the staged PCI group, the median time between randomization and PCI for nonculprit lesions was 37 days, and 2.6% of patients had their nonculprit lesion PCI as an outpatient procedure.
Stähli reported a lower rate of the primary outcome in the immediate PCI arm compared with the staged PCI arm (8.5% vs. 16.3%) and estimated a nearly 50% reduced risk for the primary outcome by 1 year with immediate PCI (HR = 0.52; 95% CI, 0.38-0.72; P for noninferiority < .001; P for superiority < .001).
The reduced risk observed with immediate compared with staged PCI was primarily driven by lower rates of nonfatal MI (2% vs. 5.3%; HR = 0.36; 95% CI, 0.16-0.8) and unplanned ischemia-driven revascularization (4.1% vs. 9.3%; HR = 0.42; 95% CI, 0.24-0.74), according to the presentation.
Stähli reported no significant differences between the groups in rates of all-cause death, stroke or HF hospitalization at 1 year.
“The key message of the MULTISTARS-AMI trial is that we could show that in patients with STEMI and multivessel disease, immediate multivessel PCI is noninferior to staged multi-vessel PCI based on the 1-year risk for the composite of all cause death, non-fatal myocardial infarction, stroke, unplanned ischemia-driven vascularization or hospitalization for heart failure,” Stähli said during the press conference.
Reference:
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Stähli BE, et al. Hot line 6. Presented at: European Society of Cardiology Congress; Aug. 25-28, 2023; Amsterdam (hybrid meeting).