MULTivessel Immediate versus STAged RevaScularization in Acute Myocardial Infarction - MULTISTARS AMI

Oct 16, 2023
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Author/Summarized by Author:
Dharam J. Kumbhani, MD, SM, FACC
Trial Sponsor:
Boston Scientific
Date Presented:
08/27/2023
Date Published:
10/16/2023
Date Updated:
10/16/2023
Original Posted Date:
10/16/2023
References

Contribution To Literature:

The MULTISTARS AMI trial showed that immediate PCI is superior to staged PCI (median of 37 days following index PCI) among hemodynamically stable patients presenting with STEMI and with evidence of at least one other nonculprit vessel that was amenable to PCI.

Description:

The goal of the trial was to compare the safety and efficacy of immediate vs. staged/delayed percutaneous coronary intervention (PCI) of nonculprit vessel(s) among hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD), who had undergone successful primary PCI of the infarct-related coronary artery.

Study Design

Eligible patients were randomized in a 1:1 open-label fashion to either immediate PCI (n = 418) or staged PCI (n = 422). In the immediate group, PCI of nonculprit lesions was performed immediately after revascularization of the infarct-related artery during the same procedure. In the staged group, PCI of nonculprit lesions was performed within 19-45 days after revascularization of the infarct-related artery (median 37 days). A third-generation, biodegradable-polymer, everolimus-eluting Synergy stent (Boston Scientific Corporation, Marlborough, MA) was recommended for PCI. Fractional flow reserve (FFR) and intravascular ultrasound (IVUS) use was up to individual operators.

  • Total screened: 2,907
  • Total number of enrollees: 840
  • Duration of follow-up: 30 months
  • Mean patient age: 65 years
  • Percentage female: 22%

Inclusion criteria:

  • Acute STEMI within 24 hours of symptom onset
  • Found to have multivessel CAD, defined as at least one additional angiographically relevant (≥70% diameter stenosis on coronary angiography based on visual estimation) stenosis in a nonculprit coronary artery that was ≥2.25-5.75 mm in diameter
  • Successful PCI of the culprit artery
  • Hemodynamically stable
  • At least one additional angiographically relevant lesion in a non–infarct-related artery suitable for PCI

Other salient features/characteristics:

  • White race: 98%
    Location of MI: Anterior: 40%, lateral: 52%
  • Location of nonculprit vessel: left anterior descending 50%, left circumflex 46%, right coronary artery 34%
  • Radial access for initial procedure: 73%

Cross-over from the immediate group to the staged group occurred in 2.9%, while cross-over from the staged group to the immediate group was not observed.

  • FFR use: 2.9% vs. 9.3%
  • Contrast use during index procedure: 250 vs. 170 cc

Principal Findings:

The primary endpoint, (all-cause death, nonfatal MI, stroke, unplanned ischemia-driven target lesion revascularization [ID-TLR], hospitalization for heart failure) at 1 year, for immediate vs. staged PCI, was: 8.5% vs. 16.3% (relative risk 0.52, 95% confidence interval 0.38-0.72; p for noninferiority < 0.001; p for superiority < 0.001).

  • All-cause mortality: 2.9% vs. 2.6%
  • Nonfatal MI: 2.0% vs. 5.3% (p < 0.05)
  • ID-TLR: 4.1% vs. 9.3% (p < 0.05)

Secondary outcomes for immediate vs. staged PCI:

  • Stent thrombosis: 1.2% vs. 1.4% (p > 0.05)
  • Acute kidney injury: 3.6% vs. 2.9% (p > 0.05)
  • Major bleeding: 3.1% vs. 4.8% (p > 0.05)

Interpretation:

The results of this trial indicate that immediate PCI is superior to staged PCI (median of 37 days following index PCI) among hemodynamically stable patients presenting with STEMI and with evidence of at least one other nonculprit vessel that was amenable to PCI. Benefit was driven by a reduction in nonfatal MI and ID-TLR during follow-up. Biologically, this is likely a manifestation of the unstable milieu created in the entire coronary tree from inflammation in the culprit vessel. Earlier optical coherence tomography studies have reported a large proportion of thin-cap fibroatheroma in nonculprit obstructive lesions.

The use of functional testing and intravascular imaging was low in this trial. These findings are an extension of the COMPLETE trial, which showed that among patients with STEMI and multivessel disease undergoing primary PCI, complete revascularization was superior to culprit-only revascularization. In that trial, complete revascularization was beneficial if performed either during or after the index hospitalization (event curves diverged after ~45 days). The current trial suggests that complete revascularization during the index procedure was a better strategy. It is unclear if staged PCI during the index hospitalization (but not in the same setting) would be equally effective.

References:

Highlighted text has been updated as of October 16, 2023.

Stähli BE, Varbella F, Linke A, et al., on behalf of the MULTISTARS AMI Investigators. Timing of Complete Revascularization With Multivessel PCI for Myocardial Infarction. N Engl J Med 2023;389:1368-79.

Jones WS. Editorial: Timing Is Everything — Evidence for When to Perform Complete Revascularization in STEMI. N Engl J Med 2023;389:1427-8.

Presented by Dr. Barbara Elisabeth Stahli at the European Society of Cardiology Congress, Amsterdam, Netherlands, August 27, 2023.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Interventions and ACS, Interventions and Coronary Artery Disease

Keywords: Acute Coronary Syndrome, Coronary Artery Disease, ESC Congress, ESC23, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention


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