Diabetes and the timing of complete revascularization in STEMI with multivessel disease: insights from the OPTION–STEMI trial

Background

In patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease, complete revascularization improves outcomes, but the optimal timing of non-culprit lesion treatment remains uncertain. Diabetes mellitus is associated with more extensive coronary disease and higher ischemic and renal risk, raising the possibility that diabetes may modify the relative benefit of immediate versus staged complete revascularization.

Methods

The OPTION–STEMI trial enrolled 994 patients undergoing primary PCI for STEMI with multivessel disease. Patients were randomized to immediate or staged complete revascularization. Clinical outcomes at 1 year were compared according to diabetes status. The primary endpoint was a composite of all-cause death, non-fatal myocardial infarction, or unplanned revascularization. Baseline clinical and procedural characteristics were evaluated across diabetes and treatment groups, and hazard ratios with interaction p-values were calculated to assess whether diabetes modified the treatment effect.

Results

Among the 994 patients, 416 (41.9%) had diabetes mellitus. Compared with non-diabetic patients, those with diabetes had a higher prevalence of hypertension (62.5% vs. 41.2%), dyslipidemia (63.9% vs. 53.5%), previous myocardial infarction (10.6% vs. 5.5%), and chronic kidney disease (10.3% vs. 4.8%). At 1 year, diabetic patients experienced higher rates of all-cause death (8.9% vs. 4.5%), cardiovascular death (7.0% vs. 3.5%), heart failure rehospitalization (7.0% vs. 2.9%), and contrast-induced nephropathy (7.8% vs. 4.3%).

Within the diabetes subgroup, the primary endpoint occurred in 14.7% of the immediate group and 13.2% of the staged group (HR 1.10, 95% CI 0.66–1.85). In the non-diabetes subgroup, the primary endpoint occurred in 11.8% and 8.9%, respectively (HR 1.37, 95% CI 0.82–2.29). (Figure 1, 2) There was no significant interaction between diabetes status and treatment strategy for the primary endpoint (interaction p=0.555). Secondary outcomes—including all-cause death, cardiovascular death, non-fatal myocardial infarction, and unplanned revascularization—did not differ significantly between immediate and staged strategies in either subgroup. Contrast-induced nephropathy showed a significant interaction (p=0.036), with staged procedures associated with higher incidence among non-diabetic patients. (Figure 1)

Conclusion

Among patients with STEMI and multivessel disease, immediate and staged complete revascularization resulted in comparable 1-year clinical outcomes regardless of diabetes status. Although diabetic patients exhibited higher overall risk, diabetes did not modify the relative effectiveness of the two revascularization strategies. These findings suggest that the timing of complete revascularization may be selected independently of diabetes status in clinical decision-making.