Complete vs. Culprit-Only Revascularization in Older Patients with ST-segment Elevation Myocardial Infarction: An Individual Patient Meta-Analysis

Circulation, Ahead of Print. Background:Complete revascularization is the standard treatment for patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease. The Functional Assessment in Elderly MI Patients with Multivessel Disease (FIRE) trial confirmed the benefit of complete revascularization in a population of older patients, but the follow-up is limited to 1 year. Therefore, the long-term benefit ( > 1-year) of this strategy in older patients is debated. To address this, an individual patient data meta-analysis was conducted in STEMI patients aged 75 years or older enrolled in randomized clinical trials investigating complete vs. culprit-only revascularization strategies.Methods:PubMed, Embase, and the Cochrane database, were systematically searched to identify randomized clinical trials comparing complete vs. culprit-only revascularization. Individual patient-level data were collected from the relevant trials. The primary endpoint was death, myocardial infarction (MI), or ischemia-driven revascularization. The secondary endpoint was cardiovascular death or myocardial infarction.Results:Data from seven RCTs, encompassing 1733 patients (917 randomized to culprit-only and 816 to complete revascularization), were analyzed. The median age was 79 [77-83] years. Females were 595 (34%). Follow-up ranged from a minimum of six months to a maximum of 6.2 years (median 2.5 [1-3.8] years). Complete revascularization reduced the primary endpoint up to four years (HR 0.78, 95%CI 0.63-0.96), but not at the longest available follow-up (HR 0.83, 95%CI 0.69-1.01). Complete revascularization significantly reduced the occurrence of cardiovascular death or MI at the longest available follow-up (HR 0.76, 95%CI 0.58-0.99). This was observed even when censoring the follow-up at each year. Long-term rate of death did not differ between complete and culprit-only revascularization arms.Conclusions:In this individual patient data meta-analysis of older STEMI patients with multivessel disease, complete revascularization reduced the primary endpoint of death, MI or ischemia-driven revascularization up to 4-year. At the longest follow-up, complete revascularization reduced the composite of cardiovascular death or MI, but not the primary endpoint.Clinical Study Registration:PROSPERO CRD42022367898

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Settembre 2024

Sublobar Resection vs Lobectomy for High-Risk Stage I Non–Small Cell Lung Carcinoma

The Cancer and Leukemia Group B (CALGB140503; also known as ALLIANCE) is a phase 3 trial that demonstrated that peripheral (outer third of lung) non–small cell lung carcinoma (NSCLC) with tumor size 2 cm or smaller and lymph node (LN) negative for metastasis, sublobar resection (defined as wedge resection or segmentectomy) compared to lobectomy was not inferior in disease-free survival (DFS) and overall survival (OS). The Japan Clinical Oncology Group (JCOG0802; also known as West Japan Oncology Group WJOG4607L study) is also a phase 3 trial that revealed that peripheral NSCLC with tumor size 2 cm or smaller with consolidation to tumor ratio more than 0.5 and LN negative for metastasis, segmentectomy (wedge resection was not allowed) compared to lobectomy was not inferior in relapse-free survival (RFS) and OS. Both trials are practice changing and challenged the prior standard of care of lobectomy for peripheral tumors 3 cm and smaller and LN negative for metastasis as established by the Lung Cancer Study Group.

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Settembre 2024