The optimal timing for complete revascularisation in patients with ST-segment elevation myocardial infarction (STEMI) and multi-vessel disease who also present with heart failure is a key clinical question. A pre-specified subgroup analysis of the OPTION-STEMI trial suggests that a staged approach may be preferable to immediate complete revascularisation in this high-risk patient group.¹

Methodology

The OPTION-STEMI (Optimal Timing of Fractional Flow Reserve-Guided Complete Revascularization for Non-Infarct-Related Artery in ST-segment Elevation Myocardial Infarction with Multivessel Disease) trial was a randomised study comparing immediate versus staged complete revascularisation during the index admission. This analysis focused on a subgroup of 329 out of 994 total patients (33.1%) who had heart failure (defined as Killip class II or III) on admission. Patients in cardiogenic shock were not included. The primary endpoint was a composite of death from any cause, non-fatal myocardial infarction, or any unplanned revascularisation at 1-year follow-up.

Results

Overall, the main trial did not find immediate complete revascularisation to be non-inferior to a staged strategy. The subgroup analysis revealed a significant interaction between heart failure status and the assigned treatment strategy (p=0.043). In patients with heart failure, immediate complete revascularisation was associated with a significantly higher incidence of the primary endpoint at 1 year compared to the staged approach (22.8% vs 13.3%; HR 1.79; 95% CI [1.05–3.04]). Conversely, in patients without heart failure at admission, there was no significant difference in the primary endpoint rate between the immediate and staged groups (8.0% vs 9.5%; HR 0.84; 95% CI [0.50–1.40]). Patients with heart failure also had a higher overall risk of the primary endpoint compared to those without (18.2% vs 8.7%; adjusted HR 1.63; 95% CI [1.11–2.40]; p=0.013).

In Practice

These findings suggest that for patients with STEMI and multi-vessel disease complicated by heart failure, a staged revascularisation strategy during the initial hospitalisation may lead to better outcomes than performing an immediate complete revascularisation. The authors of the study note that their "subgroup analysis suggests that the worse outcomes with immediate complete revascularisation may be limited to patients with heart failure at admission."

Next Steps

The investigators conclude that further studies are needed to confirm the non-inferiority of immediate complete revascularisation compared with a staged approach specifically in the population of STEMI patients without heart failure.

References

1. Kim MC, Ahn JH, Hyun DY, et al. Complete revascularization timing in ST-segment elevation myocardial infarction and multivessel disease with heart failure: the OPTION–STEMI trial. _European Heart Journal_ 2026;47(12):1435–1452. https://doi.org/10.1093/eurheartj/ehaf924.

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