Complete revascularization versus culprit-only revascularization in older adults with ST-elevation myocardial infarction: Systematic review and meta-analysis of randomized controlled trials

IF 4.3 2区医学 Q1 GERIATRICS & GERONTOLOGY

Journal of the American Geriatrics Society Pub Date : 2024-12-05 DOI:10.1111/jgs.19295

Dae Yong Park MD, Jiun-Ruey Hu MD, MPH, Jennifer Frampton DO, MPH, Jennifer Rymer MD, MBA, Abdulla Al Damluji MD, PhD, Michael G. Nanna MD, MHS

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引用次数: 0

Abstract

Background

Randomized controlled trials (RCTs) of complete revascularization (CR) versus culprit-only revascularization (COR) in patients with ST-elevation myocardial infarction (STEMI) have shifted the recommendation for CR from class III to class I in the AHA/ACC/SCAI guidelines, but it remains unclear if the benefit of CR over COR extends to older adults, who have greater bleeding risk, comorbidity burden, and complexity of lesions. We performed a meta-analysis to place the results of the previous RCTs in the context of the recently published FIRE trial and the subgroup analysis of the COMPLETE trial in adults ≥75 years old.

Methods

We searched the literature from inception to October 21, 2023. RCTs of CR versus COR in STEMI were selected if it reported results for older adults, defined as either age > 65 years or > 75 years. Integrated hazard ratios (HRs) were calculated using random effects models. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes were major bleeding and contrast-associated acute kidney injury (CA-AKI).

Results

In this meta-analysis of 5 RCTs including 3513 older adults, CR was associated with a lower hazard of MACE than COR (HR 0.60, 95% CI 0.37–0.99, p = 0.047). Sensitivity analysis including trials that defined older adults as age > 65 years resulted in a lower hazard of MACE with CR versus COR, but not in trials that defined older adults as age > 75 years. There was no difference in the hazard of major bleeding or CA-AKI between CR and COR.

Conclusions

In this largest meta-analysis to date investigating CR compared with COR in older adults with STEMI, CR was associated with reduced MACE without a concomitant increase in major bleeding or CA-AKI compared with COR. These results can help cardiologists and geriatricians involved in shared decision-making with patients and caregivers when contemplating whether to pursue CR in older adults.

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老年st段抬高型心肌梗死患者的完全血运重建术vs单纯罪魁祸首血运重建术：随机对照试验的系统评价和荟萃分析

背景：st段抬高型心肌梗死（STEMI）患者完全血运重建术（CR）与单纯罪犯血运重建术（COR）的随机对照试验（RCTs）已经将AHA/ACC/SCAI指南中推荐的完全血运重建术（CR）从III级改为I级，但目前尚不清楚CR优于COR的益处是否适用于出血风险更大、合病负担更重、病变更复杂的老年人。我们进行了一项荟萃分析，将之前的随机对照试验的结果与最近发表的FIRE试验和COMPLETE试验的亚组分析相结合，受试者为≥75岁的成年人。方法：检索自成立至2023年10月21日的文献。选择STEMI中CR与COR的随机对照试验，如果它报告了老年人的结果，定义为65岁或75岁。采用随机效应模型计算综合风险比（hr）。主要终点为主要不良心血管事件（MACE）。次要结局是大出血和对比剂相关急性肾损伤（CA-AKI）。结果：在这项包含3513名老年人的5项随机对照试验的荟萃分析中，CR与MACE的风险比COR低（HR 0.60, 95% CI 0.37-0.99, p = 0.047）。敏感性分析包括将老年人定义为bb0 ~ 65岁的试验，结果显示CR与COR合并MACE的风险较低，但在将老年人定义为bb1 ~ 75岁的试验中没有出现这种情况。结论：在这项迄今为止最大的荟萃分析中，研究了老年STEMI患者的CR与COR的比较，CR与MACE降低相关，而与COR相比，CR并未伴随大出血或CA-AKI的增加，这些结果可以帮助心脏病学家和老年医生在考虑是否对老年人进行CR时与患者和护理人员共同决策。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Journal of the American Geriatrics Society 医学-老年医学

CiteScore

10.00

自引率

6.30%

发文量

504

审稿时长

3-6 weeks

期刊介绍： Journal of the American Geriatrics Society (JAGS) is the go-to journal for clinical aging research. We provide a diverse, interprofessional community of healthcare professionals with the latest insights on geriatrics education, clinical practice, and public policy—all supporting the high-quality, person-centered care essential to our well-being as we age. Since the publication of our first edition in 1953, JAGS has remained one of the oldest and most impactful journals dedicated exclusively to gerontology and geriatrics.