Park Dae Yong, Hu Jiun-Ruey, Frampton Jennifer, Rymer Jennifer, Al Damluji Abdulla, Nanna Michael G
Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA.
Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA.
J Am Geriatr Soc. 2025 Mar;73(3):874-880. doi: 10.1111/jgs.19295. Epub 2024 Dec 5.
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.
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).
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.
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.
在ST段抬高型心肌梗死（STEMI）患者中，完全血运重建（CR）与仅对罪犯病变进行血运重建（COR）的随机对照试验（RCT）已使美国心脏协会（AHA）/美国心脏病学会（ACC）/心血管造影和介入学会（SCAI）指南中对CR的推荐从III类转变为I类，但CR相对于COR的益处是否扩展到老年患者仍不清楚，这些老年患者出血风险更高、合并症负担更重且病变更复杂。我们进行了一项荟萃分析，以结合最近发表的FIRE试验结果以及COMPLETE试验中≥75岁成年人的亚组分析，来考量先前RCT的结果。
我们检索了从开始到2023年10月21日的文献。如果报告了年龄>65岁或>75岁的老年患者结果，则选择STEMI患者中CR与COR对比的RCT。使用随机效应模型计算综合风险比（HR）。主要结局是主要不良心血管事件（MACE）。次要结局是大出血和造影剂相关急性肾损伤（CA-AKI）。
在这项纳入3513名老年患者的5项RCT的荟萃分析中，CR与较低的MACE风险相关，低于COR（HR 0.60，95%CI 0.37 - 0.99，p = 0.047）。将老年患者定义为年龄>65岁的试验进行敏感性分析，结果显示CR相对于COR有较低的MACE风险，但将老年患者定义为年龄>75岁的试验未显示此结果。CR与COR在大出血或CA-AKI风险方面无差异。
在这项迄今为止最大规模的针对STEMI老年患者中CR与COR对比的荟萃分析中，与COR相比，CR与MACE减少相关，且未伴随大出血或CA-AKI增加。这些结果有助于参与与患者及护理人员共同决策的心脏病专家和老年病专家，在考虑是否对老年患者进行CR时做出判断。
