Complete versus culprit-only percutaneous coronary intervention in elderly patients with acute coronary syndrome and multivessel coronary artery disease: A systematic review and meta-analysis

Background: Culprit-only percutaneous coronary intervention (PCI) is commonly performed for acute coronary syndrome (ACS) with multivessel coronary artery disease (MVD) in the elderly. Complete revascularization has been shown to benefit the general population, yet its safety and efficacy in older patients are uncertain. Methods: Following PRISMA guidelines, we systematically searched PubMed, Embase, and Cochrane databases for randomized controlled trials (RCTs) comparing complete versus culprit-only PCI in patients ≥65 years old with ACS and MVD. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes included myocardial infarction (MI), ischemia-driven revascularization (IDR), all-cause mortality, and cardiovascular mortality. Data were pooled using a random effects model with a restricted maximum likelihood estimator to generate risk ratios (RRs). Results: Five RCTs with 4105 patients aged ≥65 years were included. Compared with culprit-only PCI, complete revascularization reduced MI (RR 0.65; 95 % CI 0.49–0.85; p < 0.01). MACE (RR 0.75; 95 % CI 0.54–1.05; p = 0.09) and IDR (RR 0.41; 95 % CI 0.16–1.04; p = 0.06) were not significantly different between both strategies among those aged ≥65. However, there was a significant reduction in MI (RR 0.69; 95 % CI 0.49–0.96; p-value = 0.03), MACE (RR 0.78; 95 % CI 0.65–0.94; p < 0.01), and IDR (RR 0.60; 95 % CI 0.41–0.89; p < 0.01) in those aged ≥75. Conclusions: In elderly patients aged ≥65 years with ACS and MVD, a strategy of complete revascularization by PCI reduces MI compared to culprit-only PCI with no significant difference in MACE and IDR. However, complete revascularization reduced MI, MACE, and IDR in those aged ≥75 years suggesting a possible benefit in this age group.