MULTISTARS AMI Trial Investigates Timing of Complete Revascularization for Acute Myocardial Infarction

August 27, 2023—The European Society of Cardiology (ESC) announced the MULTISTARS AMI trial found that immediate complete revascularization at the time of primary percutaneous coronary intervention (PCI) was noninferior to staged (within 19 to 45 days) multivessel PCI among hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease.

Principal investigator Barbara Stähli, MD, presented the findings at the ESC Congress 2023 held August 25-28 in Amsterdam, the Netherlands. In 2020, Dr. Stähli et al published the rationale and design of the MULTISTARS AMI trial in the American Heart Journal (2020;228:98-108).

MULTISTARS AMI—“multivessel immediate versus staged revascularization in acute myocardial infarction”—included patients with acute STEMI (presenting within 24 hours of symptom onset) and multivessel coronary artery disease (defined as at least one coronary lesion with ≥ 70% diameter stenosis on coronary angiography based on visual estimation in a nonculprit coronary artery of ≥ 2.25 and ≤ 5.75 mm in diameter), who were hemodynamically stable after successful primary PCI of the infarct-related coronary artery.

As summarized in the ESC press release, the trial enrolled 840 patients from 37 sites in Europe. The average age of patients was 65 years and 21.2% were women. Patients in the study were randomized (1:1) to immediate or staged (within 19 to 45 days) PCI of the nonculprit lesions.

The primary endpoint was a composite of all-cause death, nonfatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure within 1 year after randomization.

At 1 year, the primary endpoint occurred in 35 (8.5%) patients in the immediate group and in 68 (16.3%) patients in the staged group (risk ratio, 0.52; 95% CI, 0.38 to 0.72; P < .001 for noninferiority; P < .001 for superiority). The median time interval from randomization to staged procedures in the staged group was 37 (interquartile range 30-43) days.

The ESC press release further advised that nonfatal myocardial infarction occurred in eight (2%) patients in the immediate group and in 22 (5.3%) patients in the staged group (hazard ratio [HR], 0.36; 95% CI, 0.16 to 0.80), and unplanned ischemia-driven revascularization was performed in 17 (4.1%) patients in the immediate group and in 39 (9.3%) patients in the staged group (HR, 0.42; 95% CI, 0.24 to 0.74). Rates of all-cause death, stroke, and hospitalization for heart failure did not differ between groups.

“MULTISTARS AMI addresses the clinically important question of the optimal timing for a complete revascularization of patients with STEMI and multivessel coronary artery disease,” commented Dr. Stähli in the ESC press release. “The trial has implications for clinical practice, as it demonstrated that immediate PCI of nonculprit lesions is as effective and safe as a staged procedure. Results were generally consistent across prespecified key subgroups, particularly among women and men, young and older patients, and patients with or without diabetes.”