Summary: The recent MULTISTARS AMI trial reveals significant findings, indicating that immediate multivessel PCI is non-inferior to staged procedures for patients with STEMI and multivessel coronary artery disease. This approach potentially alters the course of treatment by reducing serious cardiac events, thereby influencing guidelines on the optimal timing for such interventions.
Multivessel coronary artery disease is common in patients with ST-segment elevation myocardial infarction (STEMI), and it is associated with an increased risk of recurrent myocardial infarction and mortality. Complete revascularisation with multivessel percutaneous coronary intervention (PCI) was showed to be better than culprit lesion-only PCI in reducing risk of cardiovascular death and myocardial infarction at one year. While current guideline recommendations mirror do recommend multivessel PCI, there is still no guidance as to when revascularisation of non-culprit lesions should be performed.
The MULTISTARS AMI trial hopes to provide an answer to this, by investigating whether immediate multivessel PCI at the time of primary PCI provides the same benefits as staged multivessel PCI (PCI of non-culprit lesion was performed between 19 – 45 days after PCI of index lesion). This was designed to be a non-inferiority trial. The trial recruited a total of 840 patients who presented with an acute STEMI within 24 hours after symptom onset and found to have multivessel coronary artery disease. 418 patients were assigned to the immediate group and 422 were assigned to the staged group. Patients have to be hemodynamically stable post index PCI, with at least one additional angiographically relevant lesion in a non-infarct related artery that was suitable for PCI. After completion of the respective treatment interventions, follow up was performed at 30 days, 6 months and 1 year.
Most patients in each group had either the left main or right coronary artery as the main culprit lesion. The majority of the non-culprit lesions were located at the left anterior descending coronary artery. There were 12 patients in the immediate group who crossed over to the staged group.
At the end of 1 year, the primary endpoint of a composite of death from any cause, nonfatal myocardial infarction, stroke, unplanned ischemia-driven revascularisation or hospitalisation for heart failure occurred in 8.5% of the patients in the immediate group and 16.3% of the staged group. These results were significant for noninferiority. The secondary endpoint, which includes a composite of death from any cause, nonfatal myocardial infarction, stroke, unplanned ischemia-driven revascularisation or hospitalisation for heart failure at 6 months, occurred in 5.3% of the patients in the immediate group and 14.1% of the patients in the staged group. The percentage of patients with primary endpoint did not differ significantly in both groups between months 7 – 1 year.
The study concluded that immediate multivessel PCI was non-inferior to staged PCI with respect to the risk of a composite of death from any cause, nonfatal myocardial infarction, stroke, unplanned ischemia-driven revascularisation or hospitalisation for heart failure at 1 year. Nonfatal myocardial infarction and unplanned ischemia-driven myocardial infarction occurred in more patients in the staged multivessel PCI, particularly in the first 45 days after randomisation. This might be due to unstable plaque features in non-culprit lesions, which has a higher risk of plaque rupture and subsequent coronary events when PCI of non-culprit lesions is performed as a staged intervention. Therefore, by improving coronary blood flow in non-culprit vessels with immediate PCI may reduce the ischemic burden. In addition, performing an immediate multivessel PCI may reduce total contrast exposure and minimise hospital admissions.
The results of these trials may not be generalisable to all patients eligible for PCI with multivessel coronary artery disease, given that patients with cardiogenic shock, previous coronary bypass surgery, stent thrombosis, in-stent restenosis and chronic total occlusion were excluded. However, it still provides valuable evidence on the timing at which PCI should be performed, since the data is scarce.
In conclusion, the MULTISTAR AMI trial has shown that immediate PCI is non-inferior to staged PCI in patients with STEMI and multivessel coronary artery disease in reducing the risk of a composite of death from any cause, nonfatal myocardial infarction, stroke, unplanned ischemia driven revascularisation or hospitalisation for heart failure at one year.
Reference:
- Stähli BE, Varbella F, Linke A, Schwarz B, Felix SB, Seiffert M, et al. Timing of complete revascularization with Multivessel PCI for myocardial infarction. New England Journal of Medicine. 2023;389(15):1368–79. doi:10.1056/nejmoa2307823
