Meta-analysis comparing immediate versus staged complete revascularization for ST-elevation myocardial infarction with multivessel disease.

Abstract

Patients with ST-segment elevation myocardial infarction (STEMI) frequently present with multivessel coronary artery disease (CAD) during primary percutaneous coronary intervention (PCI), and the optimal timing of complete revascularization (CR) in these cases remains uncertain. This study aims to assess major adverse cardiovascular events (MACE) and procedural complications in STEMI patients with multivessel CAD undergoing immediate (index procedure) versus staged CR. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing immediate to staged complete revascularization (CR) in STEMI and multivessel CAD. Trials were identified via a systematic search of MEDLINE, Embase, and Cochrane Libraries from database inception to March 6, 2024. The data were analyzed using RevMan software. Five RCTs (n=1,415) were included in our study, which showed no significant differences in MACE (13.3% vs. 9.8%; RR: 1.07, 95% CI [0.62, 1.83]), all-cause mortality (3% vs. 4.55%; RR: 0.70, 95% CI [0.41, 1.21]), or myocardial infarction (4.5% vs. 2.6%; RR: 1.43, 95% CI [0.58, 3.55]) at a weighted mean follow-up duration of 16 months. However, the staged group had a higher rate of unplanned revascularization (8.6% vs. 4.4%; RR: 1.92, 95% CI [1.21, 3.04]). In conclusion, in STEMI patients with multivessel CAD, at a mean follow-up of approximately 1.3 years, there is no significant difference in immediate versus staged revascularization for MACE; however, staged revascularization was associated with a significantly higher incidence of unplanned ischemia-driven revascularization. Staged revascularization within the index hospitalization may be as effective as immediate complete revascularization; further trials are needed to confirm this. CONDENSED ABSTRACT We conducted a meta-analysis of 5 randomized controlled trials comparing immediate to staged CR in STEMI patients with multivessel CAD. There was no significant difference in major adverse cardiovascular events, all-cause mortality, and myocardial infarction rates between immediate and staged complete revascularization. However, staged revascularization was associated with a higher incidence of unplanned ischemia-driven revascularization.