Optimal Timing of Complete Revascularization in Patients With ST-Elevation Myocardial Infarction and Multivessel Disease: A Systematic Review and Meta-Analysis

Complete revascularization (CR) in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) is recommended, but the timing of revascularization, either immediate or staged remains a topic of debate. A systematic search of MEDLINE, Scopus, and Cochrane databases was performed to identify randomized controlled trials (RCTs) that evaluated patients with STEMI and MVD and compared outcomes between immediate CR versus staged CR. The primary outcome was major adverse cardiovascular events. Eleven RCTs were included in this analysis with 4,472 patients assessed at a weighted mean follow-up of 18.5 months. Patients were 79% male with an average age of 64 years. Five RCTs utilized some degree of intravascular imaging or physiology, 7 RCTs explicitly excluded left main (LM) disease, and 6 RCTs exclusively utilized drug-eluting stents (DES). Compared to staged CR, immediate CR did not significantly reduce the incidence of major adverse cardiovascular events (risk ratios [RR] 0.92 [0.73, 1.17]), all-cause mortality (RR 1.31 [0.97, 1.78]), cardiovascular mortality (RR 1.28 [0.87, 1.90]), recurrent myocardial infarction (MI) (RR 0.78 [0.57, 1.07]), unplanned revascularization (RR 0.87 [0.67, 1.14]), or stent thrombosis (RR 1.39 [0.79, 2.43]). Safety endpoints were comparable between both groups: stroke (RR 0.91 [0.51, 1.62]), major bleeding (RR 0.76 [0.49, 1.18]), and acute nephropathy (RR 0.88 [0.59, 1.31]). Sensitivity analysis demonstrated consistent findings regarding the primary outcome across all scenarios. Immediate and staged CR demonstrated similar efficacy and safety. In conclusion, these neutral findings were consistent despite heterogeneity across RCTs, and support a revascularization approach incorporating anatomic complexity, physiology, procedural logistics, and patient-specific factors when determining the optimal timing of CR in patients with STEMI and MVD.