Complete Percutaneous Revascularization in Patients Presenting With ST-Segment Myocardial Infarction Who Have Multivessel Coronary Disease: A Meta-Analysis of Randomized Trials

Abstract

Background: In patients presenting with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD), the benefit of complete revascularization (CR) with respect to hard endpoints (death or myocardial infarction [MI]) and the role of invasive physiological assessment remains uncertain.

Methods: This systematic review and meta-analysis included randomized trials comparing CR with culprit only revascularization (COR) or immediate versus delayed CR in patients with STEMI and MVD. Random-effects meta-analysis was performed comparing clinical outcomes in individual groups. The primary endpoint was the composite of death or MI.

Results: Sixteen trials were identified including a total of 15,160 patients. Compared to a COR strategy, CR significantly reduced the risk of death/MI (RR: 0.68, CI = 0.54–0.85). Angiography-guided CR significantly reduced the risk of death/MI compared to a COR approach (RR: 0.57, CI = 0.40–0.83, p < 0.05). Seven trials evaluated physiology-guided CR and did not demonstrate a significant difference for death/MI compared to a COR approach (RR: 0.74, CI = 0.54–1.01, p = 0.06). Meta-regression showed that age was significantly associated with death/MI (p = 0.026), and the timing of CR was associated with a reduced risk of ischemia-driven revascularization (p = 0.045).

Conclusion: CR was associated with a lower risk of death or MI compared to COR. Compared to COR, angiography-guided CR was associated with a lower incidence of death or MI; however, these benefits were not observed in the physiology-guided CR group. There is a need for further head-to-head studies investigating the role of physiology-guided risk-stratification of nonculprit stenoses.