Immediate Versus Staged Complete Revascularization in Multivessel Disease and STEMI

Abstract

Background

For patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease, complete revascularization is recommended. The timing of nonculprit lesion intervention, either immediately during the index procedure or staged at a later time, has been investigated in randomized controlled trials (RCTs).

Objectives

This study sought to perform a meta-analysis of RCTs comparing immediate vs staged complete revascularization in patients with multivessel disease presenting with STEMI.

Methods

We conducted a frequentist, pairwise meta-analysis. Studies were selected based on the following inclusion criteria: multicenter RCTs comparing immediate vs staged nonculprit revascularization in patients presenting with STEMI; exclusive use of second-generation (or newer) drug-eluting stents; a follow-up duration of ≥1 year; and publication in a peer-reviewed journal. The primary outcome of interest was all-cause mortality, whereas secondary outcomes included myocardial infarction (MI), cardiac death, and unplanned revascularization. Summary estimates were computed using random-effects models with inverse-variance weighting based on trial-level HRs and 95% CIs. The study protocol was registered on PROSPERO (CRD420251124207).

Results

After a systematic search, 4 randomized trials comprising 2,651 patients were included in the meta-analysis. The risk of all-cause death at 1-year was higher with immediate complete revascularization (HR: 1.50; 95% CI: 1.02-2.21; P = 0.04; prediction interval [PI]: 0.80-2.81; I² = 0%; t² = 0). Immediate complete revascularization reduced the risk of recurrent MI when using the protocol specified definitions which included procedural MI (HR: 0.58; 95% CI: 0.36-0.94; P = 0.02; PI: 0.22-1.54; I² = 0%; t² = 0.034) but did not reduce risk of spontaneous MI (HR: 0.91; 95% CI: 0.55-1.48; P = 0.90; PI: 0.41-2.00; I² = 0%; τ² = 0.00). The risk of cardiac death and unplanned revascularization was comparable between the treatment groups.

Conclusions

In STEMI and multivessel disease, immediate complete revascularization may be associated with an increased risk of all-cause death at 1-year when compared with staged complete revascularization. The treatment effect on mortality should be interpreted cautiously because of the relatively low number of deaths across the 4 trials and the statistical fragility of the findings. The findings from this analysis do not support an immediate complete revascularization strategy in these patients.