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Deferred vs Immediate Stenting in Primary Percutaneous Coronary Intervention: A Collaborative Meta-analysis of
Salvatore Cassese1, Loic Belle2, Gjin Ndrepepa1
1Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.
Insights
Deferred stenting during primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) improves angiographic outcomes but not imaging or clinical results. Further trials are needed to confirm potential benefits in patients with high thrombus burden.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Imaging
Background:
- The optimal timing of stent placement during primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) is debated.
- Immediate stenting is standard, but deferred stenting is being investigated as an alternative strategy.
Purpose of the Study:
- To compare the efficacy of deferred versus immediate stenting during primary PCI in STEMI patients.
- To evaluate angiographic, imaging, and clinical outcomes in a meta-analysis of randomized trials.
Main Methods:
- A collaborative meta-analysis of study-level data from 4 randomized trials involving 1570 STEMI patients undergoing primary PCI.
- Patients were assigned to either deferred or immediate stenting, with subsequent cardiac magnetic resonance imaging (CMR).
- Primary outcomes included slow/no-reflow and microvascular obstruction (MVO); recurrent ischemia was a key secondary outcome.
Main Results:
- Deferred stenting significantly reduced the risk of slow/no-reflow (RR 0.54; P < 0.001) but showed similar risks for MVO (RR 0.93; P = 0.51) and a trend towards higher recurrent ischemia (RR 2.42; P = 0.09) compared to immediate stenting.
- Treatment effects on slow/no-reflow and MVO correlated with baseline thrombus burden and total stent length.
- Median follow-up was 9 months, with 797 participants having analyzable CMR scans.
Conclusions:
- Deferred stenting during primary PCI improves angiographic outcomes but does not enhance imaging or clinical outcomes compared to immediate stenting.
- The potential benefit of deferred stenting in reducing myocardial injury in STEMI patients with high thrombus burden requires confirmation in larger randomized trials.
Background:
The role of deferred vs immediate stenting during primary percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) remains controversial.
Methods:
We undertook a collaborative meta-analysis of study-level data by searching electronic scientific databases for investigations of primary PCI patients randomized to deferred or immediate stenting and subsequent cardiac magnetic resonance imaging. Primary angiographic and imaging outcomes were slow/no-reflow and microvascular obstruction (MVO), respectively. Main secondary outcome was recurrent ischemia.
Results:
Among 4 trials, a total of 1570 patients with STEMI were assigned to primary PCI with either deferred (n = 779) or immediate stenting (n = 791). Of these, 797 participants had analyzable cardiac magnetic resonance imaging examinations. Median clinical follow-up was 9 months. Patients treated with deferred stenting showed a lower risk of developing slow/no-reflow in the culprit vessel (risk ratio [RR], 0.54 [95% confidence interval (CI), 0.41-0.72]; P < 0.001), a similar risk for MVO (RR, 0.93 [95% CI, 0.76-1.14]; P = 0.51), and trended higher in the risk of recurrent ischemia (RR, 2.42 [95% CI, 0.88-6.63]; P = 0.09) compared with those treated with immediate stenting. The treatment effect for slow/no-reflow and MVO correlated with a thrombus score grade > 3 at the baseline angiography and with the total stent length implanted in the culprit artery.
Conclusions:
A strategy of deferred stenting during primary PCI improves angiographic but not imaging or clinical outcomes compared with immediate stenting. The potential lower risk for myocardial injury by deferred stenting in primary PCI patients with STEMI and high thrombus burden requires a confirmation in adequately sized randomized trials.
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