Parity for Prompt vs Staged STEMI Complete Revascularization: MULTISTARS-AMI

August 29, 2023

The timing of complete revascularization (CR) in patients with acute ST-elevation myocardial infarction (STEMI) and multivessel disease (MVD) may make little clinical difference.

The conclusion comes from a randomized outcomes trial of 840 patients that compared prompt same-session CR with a staged procedure carried out weeks later.

That CR is a worthy goal in such cases is largely settled, unlike the question of when to pursue revascularization of nonculprit lesions for best results. So the timing varies in practice, often depending on the patient's clinical stability, risk status, or practical issues like cath lab resources or personnel.

The new trial, MULTISTARS-AMI, supports that kind of flexibility as safe in practice. Immediate, same-session CR led to a 48% drop in risk for a broad composite primary endpoint at 1 year compared with staged CR an average of 37 days later. The finding was significant for noninferiority in the study's primary analysis and secondarily, was significant for superiority (P < .001 in both cases).

The composite endpoint included death from any cause, MI, stroke, unplanned ischemia-driven revascularization, or heart failure (HF) hospitalization.

CR's immediate effect on outcomes was numerically pronounced, but because it was prespecified as a noninferiority trial, MULTISTARS-AMI could show only that the strategy is comparable to staged CR, emphasized Barbara E. Stähli, MD, MPH, MBA, at a press conference.

Still, it appears to be the first trial of its kind to show that operators and patients can safely choose either percutaneous coronary intervention (PCI) approach and attain similar outcomes, said Stähli, University Hospital Zurich, Switzerland, MULTISTARS-AMI's principal investigator.

Not only were the two approaches similar with respect to safety, she noted, but immediate CR seemed to require less use of contrast agent and fluoroscopy. "And you have only one procedure, so there's only one arterial puncture."

Stähli formally presented MULTISTARS-AMI on August 27 at the European Society of Cardiology (ESC) Congress 2023, held in Amsterdam, the Netherlands. She is also lead author on its same-day publication in The New England Journal of Medicine.

After her presentation, invited discussant Robert A. Byrne, PhD, MD, MB, BCh, said that the trial's central message is that STEMI patients with MVD having primary PCI "should undergo complete revascularization within the first 45 days, with the timing of the non–infarct-related artery procedure individualized according to clinical risk and logistical considerations."

Still, the trial "provides evidence, but not strong evidence, of benefits with routine immediate PCI during the index procedure as compared with staged outpatient PCI," said Byrne, Mater Private Hospital and RCSI University of Medicine and Health Sciences, Dublin, Ireland.

MULTISTARS-AMI randomly assigned patients at 37 European sites to undergo same-session CR (418 patients) or CR staged 19-45 days later (422 patients).

Rates for the primary endpoint at 1 year were 8.5% and 16.3%, respectively, for a risk ratio (RR) of 0.52 (95% CI, 0.38-0.72). The difference was driven by fewer instances of nonfatal MI, 0.36 (95% CI, 0.16-0.80), and unplanned ischemia-driven revascularization, 0.42 (95% CI, 0.24-0.74), in the immediate-CR group.

The Wee Hours

Sunil V. Rao, MD, director of interventional cardiology at NYU Langone Health System, New York City, said that in general, at his center, patients who are stable with a good primary PCI outcome and whose lesions aren't very high-risk are often discharged to return later for the staged CR procedure.

But after the new insights from MULTISTARS-AMI, Rao, who is not connected to the study, told | Medscape Cardiology that immediate same-session CR is indeed likely preferable to staged CR performed weeks later.

Same-session CR, however, may not always be practical or wise, he observed. For example, some patients with STEMI can be pretty sick with MVD that involves very complex lesions that might be better handled later.

"The wee hours of the night may not be the best time to tackle such complex lesions," Rao observed. If confronted with, for example, a bifurcation that requires a complex procedure, "2 o'clock in the morning is probably not the best time to address something like that."

So the trial's more realistic translational message, he proposed, may be to perform CR after the primary PCI but during the same hospitalization, "unless there are some real mitigating circumstances." 

The trial was supported by Boston Scientific. Stähli had no disclosures. Byrne discloses research funding to his institution from Abbott Vascular, Translumina, Biosensors, and Boston Scientific. Rao had no relevant disclosures.

European Society of Cardiology Congress 2023, Hot Line 6. Presented August 27, 2023. Session

N Engl J Med. Published online August 27, 2023. Full text

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