Immediate Versus Staged Complete Revascularization for Patients With ST-Segment–Elevation Myocardial Infarction and Multivessel Disease: A Network Meta-Analysis of Randomized Trials

BACKGROUND: The comparative outcomes with immediate, staged in-hospital, and staged out-of-hospital complete revascularization for patients with ST-segment–elevation myocardial infarction and multivessel disease remain unclear. METHODS AND RESULTS: An electronic search of MEDLINE, SCOPUS, and Cochrane databases was performed through August 2023 for randomized trials evaluating immediate, staged in-hospital, and staged out-of-hospital complete revascularization for patients with ST-segment–elevation myocardial infarction and multivessel disease. The primary outcome was major adverse cardiac events (MACEs). The final analysis included 9 trials with 4270 patients. The weighted follow-up duration was 13.8 months. On pairwise meta-analysis, there were no statistically significant differences between immediate versus staged nonculprit percutaneous coronary intervention (PCI) in MACEs (odds ratio, 0.79 [95% CI, 0.54–1.16]). Network meta-analysis showed that there was no statistically significant difference in MACEs with staged in-hospital nonculprit PCI (odds ratio, 1.29– [95% CI, 0.91–1.82]) compared with immediate nonculprit PCI, while there were higher odds of MACEs with out-of-hospital nonculprit PCI (odds ratio, 1.67–[95% CI, 1.21–2.30]) compared with immediate nonculprit PCI. Compared with immediate nonculprit PCI, there were higher odds of ischemia-driven repeat revascularization with staged out-of-hospital nonculprit PCI (odds ratio, 2.26–[95% CI, 1.37–3.72]), but not with in-hospital staged nonculprit PCI. There were no significant differences for the other outcomes among the 3 strategies. CONCLUSIONS: Among patients with ST-segment–elevation myocardial infarction with multivessel disease, an immediate nonculprit PCI approach was associated with similar clinical outcomes to the staged nonculprit PCI approach. The staged out-of-hospital nonculprit PCI approach was associated with a higher incidence of MACEs compared with the other strategies, which was driven by higher risk for ischemia-driven repeat revascularization.