非罪犯血管完全血运重建与罪犯血管血运重建在伴或不伴 ST 段抬高的老年心肌梗死患者中的比较。

Complete vs Culprit-Only Revascularization in Older Patients With Myocardial Infarction With or Without ST-Segment Elevation.

机构信息

Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy.

出版信息

J Am Coll Cardiol. 2024 Nov 12;84(20):2014-2022. doi: 10.1016/j.jacc.2024.07.028. Epub 2024 Aug 31.

DOI:10.1016/j.jacc.2024.07.028

PMID:39217557

Abstract

BACKGROUND

The effectiveness of complete revascularization is well established in patients with ST-segment elevation myocardial infarction (STEMI), but it is less investigated in those with non-ST-segment elevation myocardial infarction (NSTEMI).

OBJECTIVES

This study aimed to assess whether complete revascularization, compared with culprit-only revascularization, was associated with consistent outcomes in older patients with STEMI and NSTEMI.

METHODS

In the FIRE (Functional Assessment in Elderly MI Patients with Multivessel Disease) trial, 1,445 older patients with myocardial infarction (MI) were randomized to culprit-only or physiology-guided complete revascularization, stratified by STEMI (n = 256 culprit-only vs n = 253 complete) and NSTEMI (n = 469 culprit-only vs n = 467 complete). The primary outcome comprised a composite of death, MI, stroke, or revascularization at 1 year. The key secondary outcome included a composite of cardiovascular death or MI at 1 year.

RESULTS

In the overall study population, physiology-guided complete revascularization reduced both primary and key secondary outcomes. The primary outcome occurred in 54 (21.1%) STEMI patients randomized to culprit-only vs 41 (16.2%) STEMI patients of the complete group (HR: 0.75; 95% CI: 0.50-1.13) and in 98 (20.9%) NSTEMI patients randomized to culprit-only vs 72 (15.4%) NSTEMI patients of the complete group (HR: 0.71; 95% CI: 0.53-0.97), with negative interaction testing (P for interaction, 0.846). Similarly, no signal of heterogeneity with respect to the initial clinical presentation was observed for the key secondary endpoint (P for interaction, 0.654).

CONCLUSIONS

Physiology-guided complete revascularization, compared with culprit-only revascularization, provided consistent benefit across the whole spectrum of patients with MI. (FIRE [Functional Assessment in Elderly MI Patients With Multivessel Disease]; NCT03772743).

摘要

背景

ST 段抬高型心肌梗死（STEMI）患者的完全血运重建效果已得到充分证实，但非 ST 段抬高型心肌梗死（NSTEMI）患者的相关研究则较少。

目的

本研究旨在评估与罪犯血管血运重建相比，完全血运重建在 STEMI 和 NSTEMI 老年患者中的应用是否具有一致的获益。

方法

在 FIRE（多支血管病变老年 MI 患者功能评估）试验中，1445 例心肌梗死（MI）老年患者被随机分至罪犯血管血运重建组或生理学指导下的完全血运重建组，根据 STEMI（罪犯血管血运重建 256 例，完全血运重建 253 例）和 NSTEMI（罪犯血管血运重建 469 例，完全血运重建 467 例）进行分层。主要终点为 1 年时的死亡、MI、卒中和血运重建的复合终点。关键次要终点为 1 年时心血管死亡或 MI 的复合终点。

结果

在总体研究人群中，生理学指导下的完全血运重建降低了主要终点和关键次要终点事件。在 STEMI 患者中，随机分至罪犯血管血运重建组的 54 例（21.1%）和完全血运重建组的 41 例（16.2%）患者发生了主要终点事件（HR：0.75；95%CI：0.50~~1.13），在 NSTEMI 患者中，随机分至罪犯血管血运重建组的 98 例（20.9%）和完全血运重建组的 72 例（15.4%）患者发生了主要终点事件（HR：0.71；95%CI：0.53~~0.97），交互检验 P 值为 0.846。同样，对于关键次要终点事件，也未观察到初始临床特征存在异质性的信号（交互检验 P 值为 0.654）。