Timing of Complete Revascularization in Patients With STEMI and Multivessel Disease: An Updated Meta-Analysis of Randomized Clinical Trials

Abstract

BACKGROUND: The ideal timing for complete revascularization (CR) in patients with ST-segment–elevation myocardial infarction and multivessel disease is uncertain. This meta-analysis examined outcomes of immediate CR (ICR) versus staged CR (SCR). METHODS: Four databases were searched for randomized controlled trials that compared ICR and SCR in ST-segment–elevation myocardial infarction and multivessel disease. The primary end points of interest were short-term and long-term all-cause mortality. Outcomes are presented as risk ratios for short-term outcomes and incidence rate ratios for long-term outcomes with 95% CIs. RESULTS: The analysis included 9 randomized controlled trials in which 4213 patients were enrolled. Short-term all-cause mortality occurred in 2.0% of patients after ICR compared with 1.2% of patients after SCR (risk ratio, 1.66 [95% CI, 0.99–2.78], P =0.053; I 2 =0%). Short-term cardiac death was increased after ICR (risk ratio, 2.19 [95% CI, 1.08–4.44], P =0.03; I 2 =0%). At a median 1-year follow-up, all-cause mortality occurred in 4.7% of patients after ICR compared with 3.5% of patients after SCR (incidence rate ratio, 1.40 [95% CI, 0.97–2.03], P =0.07; I 2 =0%). No significant differences were identified between the ICR and SCR strategies at either short-term or long-term follow-up for other outcomes, including myocardial infarction, repeat revascularization, stent thrombosis, stroke, major bleeding, and the composite of major adverse cardiac or cerebrovascular events. CONCLUSIONS: In hemodynamically stable patients with ST-segment–elevation myocardial infarction and multivessel disease, an ICR strategy may increase short-term cardiac death compared with SCR, and the possibility of increased early and late all-cause mortality cannot be excluded. Despite some uncertainty, these results currently favor a staged CR strategy for most patients with ST-segment–elevation myocardial infarction and multivessel disease. REGISTRATION: URL: https://www.crd.york.ac.uk/PROSPERO/ ; Unique identifier: CRD420251163719.