Timing of non-culprit revascularization in STEMI with multivessel disease: A contemporary meta-analysis of immediate and staged strategies.

Abstract

Background: Complete revascularization improves outcomes in ST-segment elevation myocardial infarction (STEMI) with multivessel coronary artery disease, but the optimal timing of non-culprit intervention-immediate, early-staged (same hospitalization), or delayed (post-discharge)-remains uncertain.

Objectives: To evaluate the effect of timing of non-culprit revascularization in STEMI.

Methods: We performed a systematic review and meta-analysis of randomized trials comparing immediate, early-staged, and delayed-staged non-culprit revascularization in STEMI. DerSimonian-Laird random-effects models pooled risk ratios (RR) with 95% confidence intervals (CI); fixed-effect and REML sensitivity analyses and parallel hard-endpoint (death plus myocardial infarction) analyses were performed.

Results: Five randomized trials contributed to the pooled timing comparisons. Versus early-staged revascularization, immediate complete PCI was not associated with improved outcomes (three trials; RR 1.25, 95% CI 0.92-1.70; I² = 0%). Versus delayed-staged strategies, immediate PCI showed a numerical event reduction (RR 0.73, 95% CI 0.37-1.45) with substantial heterogeneity (I² ≈ 88%), driven by discordant results between MULTISTARS AMI and iMODERN, the latter a hybrid strategy-plus-timing (physiology- versus imaging-guided) rather than a pure timing comparison. Hard-endpoint analyses showed no significant difference; where reported, contrast-induced nephropathy and major bleeding did not differ.

Conclusions: Immediate complete revascularization showed no clear difference in outcomes versus staged revascularization during the same hospitalization; as most trials were not powered for non-inferiority, this should not be read as equivalence. These findings support an individualized approach emphasizing timely completion rather than routine immediate multivessel PCI in stable STEMI, with staged PCI favored when lesions are complex, renal function is impaired, or physiology-guided assessment is preferred.

Condensed abstract: In this meta-analysis of direct-timing randomized trials, immediate multivessel PCI showed no benefit versus in-hospital staged revascularization and only inconsistent benefit versus delayed strategies. These data support immediate non-culprit PCI in the hemodynamically stable patient with a non-complex culprit intervention and anticipated non-complex non-culprit PCI, and staged in-hospital PCI as an equally pragmatic default, in stable STEMI with multivessel disease. Because the potential downside of brief post-discharge deferral (within 30-45 days) appears small, selected patients-such as those with significant acute kidney injury after index PCI or functionally vulnerable elderly patients who would benefit from earlier discharge-may reasonably undergo planned outpatient non-culprit revascularization.