Optimal Strategy for Complete Revascularization in ST-Segment Elevation Myocardial Infarction and Multivessel Disease: A Network Meta-Analysis.
Summary
Across 26 RCTs (n=15,902), complete revascularization reduced MACE compared with culprit-only PCI. Immediate CR further reduced MACE versus staged CR (RR 0.74), largely driven by MI reduction; the advantage attenuated when excluding procedural MI. Benefits were consistent whether guidance was angiographic or physiology-based.
Key Findings
- Complete revascularization reduced MACE vs culprit-only PCI (immediate CR RR 0.48; staged CR RR 0.65).
- Immediate CR reduced MACE vs staged CR (RR 0.74), consistent with angiographic and functional guidance.
- MI reduction with immediate CR attenuated when procedural MI was excluded (RR 0.65; 95% CI 0.36–1.16).
Clinical Implications
For hemodynamically stable multivessel STEMI, prioritize complete revascularization during the index procedure when feasible, with awareness that some MI reduction reflects procedural factors. Institutional protocols should enable immediate CR with careful lesion selection and operator expertise.
Why It Matters
This synthesis unifies disparate RCTs and provides practice-directing evidence favoring immediate complete revascularization in multivessel STEMI. It clarifies the magnitude and drivers of benefit and nuances related to procedural MI.
Limitations
- Potential trial-level heterogeneity (patient selection, operator expertise, definition of MI across trials)
- Attenuation of MI benefit after excluding procedural MI complicates interpretation of mechanism
Future Directions
Head-to-head RCTs comparing immediate vs staged CR with standardized MI definitions and patient-centered outcomes; implementation studies optimizing workflow and lesion selection.
Study Information
- Study Type
- Meta-analysis
- Research Domain
- Treatment
- Evidence Level
- I - Synthesis of randomized controlled trials providing highest-level comparative evidence
- Study Design
- OTHER