Immediate or staged revascularisation in STEMI plus multivessel disease?

Immediate multivessel percutaneous coronary intervention (PCI) was non-inferior to staged multivessel PCI in patients with ST-elevation myocardial infarction (STEMI) and multivessel disease (MVD) who had received a successful PCI of the culprit artery, according to the results of the MULTISTARS AMI study.

The MULTISTARS AMI trial (NCT03135275) assessed whether immediate multivessel PCI was non-inferior to staged PCI (within 19 to 45 days) in haemodynamically stable patients with STEMI and MVD following successful PCI of the culprit artery [1]. The study randomised 840 participants 1:1 to immediate PCI of non-culprit lesions or staged PCI of non-culprit lesions. The primary outcome was a composite of all-cause death, non-fatal MI, stroke, unplanned ischaemia-driven revascularisation, or hospitalisation for heart failure at 52 weeks. Prof. Barbara Stähli (University of Zürich, Switzerland) presented the primary findings.

Immediate PCI was non-inferior to staged PCI (RR 0.52; 95% CI 0.38–0.72; P_{non-inferiority}<0.0001). In fact, the risk for primary outcome events was significantly lower in the immediate PCI group (P=0.0004). Non-fatal MI (RR 0.36; 95% CI 0.16–0.80) and unplanned ischaemia-driven revascularisation (RR 0.42; 95% CI 0.24–0.74) appeared to occur more frequently in the staged PCI arm than in the immediate PCI arm. The results were consistent across subgroups. “Immediate PCI was non-inferior to staged PCI in patients with STEMI and MVD who underwent a successful primary PCI,” concluded Prof. Stähli.

Prof. Robert Byrne (RCSI University, Ireland), discussant of the trial, pointed out that the observed difference in MI rates between the 2 study arms was not due to an increase of spontaneous (type 1) MI in the staged PCI group but related to a higher number of procedural MI in the staged PCI group (n=12 vs n=0). “This raises some questions in relation to ascertainment bias in the immediate PCI group, where it can be difficult to detect periprocedural MI,” he argued. “Therefore, the results of the MULTISTARS AMI trial provide evidence, but not strong evidence, of benefit with routine immediate PCI during the index procedure as compared with staged outpatient PCI.”

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   1. Stähli B, et al. Multivessel immediate versus staged revascularization in acute myocardial infarction (MULTISTARS AMI): a randomized study of immediate versus staged revascularization after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. Hot Line Session 6, ESC Congress 2023, 25–28 August, Amsterdam, the Netherlands.

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Posted on 30 October, 202323 April, 2024