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The New England Journal of MedicineComplete or Culprit-Only PCI in Older Patients with Myocardial Infarction

Revascularization in Older Patients: A New Perspective on an Old Dilemma

The study aims to shed light on the efficacy and safety of complete revascularization versus culprit-only revascularization in older patients (≥75 years) with myocardial infarction and multivessel disease. The results could have significant implications for treatment protocols in geriatric cardiology.

HCN Medical Memo
For physicians treating older patients with myocardial infarction and multivessel disease, this study suggests that opting for physiology-guided complete revascularization could reduce the risk of adverse outcomes, including death and myocardial infarction, without compromising safety. Consider revising your treatment protocols accordingly.

Study Design:
  • Multicenter, randomized trial involving older patients (median age 80) with myocardial infarction and multivessel disease.
  • 1,445 patients were randomized (720 for complete revascularization, 725 for culprit-only).
  • Participants were undergoing percutaneous coronary intervention (PCI) for the culprit lesion.
  • Two groups: one received physiology-guided complete revascularization of nonculprit lesions, the other received no further revascularization.
  • Primary outcome: a composite of death, myocardial infarction, stroke, or any revascularization at 1 year.
  • Safety assessed through a composite of contrast-associated acute kidney injury, stroke, or bleeding.

Approximately 35% of patients admitted for myocardial infarction are 75 years or older.

Key Findings:
  • A primary-outcome event occurred in 15.7% of the complete-revascularization group and 21.0% in the culprit-only group (hazard ratio, 0.73; P=0.01).
  • Cardiovascular death or myocardial infarction was lower in the complete-revascularization group (8.9% vs. 13.5%; hazard ratio, 0.64).
  • No significant difference in safety outcomes between the groups (22.5% vs. 20.4%; P=0.37).

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