Immediate revascularization tied to higher 1-year risk in STEMI with multivessel disease and heart failure

The OPTION-STEMI trial investigated the optimal timing of complete revascularization in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease. The trial compared immediate complete revascularization versus staged complete revascularization during the index admission. The primary endpoint was a composite of death from any cause, non-fatal myocardial infarction, or any unplanned revascularization at 1 year. The main trial result found immediate complete revascularization was not non-inferior to staged complete revascularization for the primary endpoint. This analysis presents a pre-specified subgroup analysis based on the presence of heart failure at admission, defined as Killip class II or III. Among 994 randomized patients, 329 (33.1%) had heart failure at admission. Patients with heart failure had a higher risk of the primary endpoint than those without (18.2% vs 8.7%; adjusted HR 1.63, 95% CI 1.11-2.40; P = .013). At 1 year, in patients with heart failure, immediate complete revascularization was associated with a higher incidence of the primary endpoint compared to staged revascularization (22.8% vs 13.3%; HR 1.79, 95% CI 1.05-3.04). In patients without heart failure, there was no significant difference in the primary endpoint between strategies (8.0% vs 9.5%; HR 0.84, 95% CI .50-1.40). A significant interaction was observed between heart failure status and the randomized strategy (P = .043). The authors conclude that while immediate revascularization was not non-inferior overall in the trial, the worse outcomes with this strategy may be limited to patients with heart failure at admission. They note further studies are required to demonstrate the non-inferiority of immediate complete revascularization compared with staged complete revascularization in patients without heart failure.

When someone has a major heart attack (STEMI) and multiple blocked arteries, doctors face a tough call: should they fix all the blockages right away, or wait a bit? This question is especially urgent if the patient also shows signs of heart failure—like being short of breath or having fluid in the lungs—when they arrive at the hospital.

A trial looked at nearly 1,000 patients in this exact situation. It found that about one-third of them had heart failure at admission. Overall, these patients were at higher risk for serious problems. The key finding was about timing. For patients with heart failure, fixing all blockages immediately was linked to worse outcomes. Within a year, 22.8% of these patients who got immediate treatment experienced a major event (death, another heart attack, or an unplanned procedure) compared to 13.3% of those who had a staged, or delayed, approach.

For patients without heart failure, the timing didn't seem to make a significant difference in their risk. The study concludes that the worse results from immediate treatment might be specific to patients who already have heart failure when they come in. More research is needed to confirm if immediate treatment is as safe as waiting for patients who aren't in heart failure.