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Immediate Versus Staged Complete Revascularization in Multivessel Disease and STEMI: A Meta-Analysis of Randomized
Daniel O'Callaghan1, Himanshu Rai1, Daniele Giacoppo1
1Cardiovascular Research Institute, Mater Private Network, Dublin, Ireland; School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland.
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.