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Immediate and Staged Complete Revascularization Show Equivalent Outcomes in STEMI with Multivessel Disease
Across six randomized controlled trials pooling 2,837 patients, immediate complete revascularization produced virtually identical rates of cardiac death compared with staged revascularization at 12 months, with no clinically meaningful difference between strategies (RR 0.99, 95% CI 0.98–1.01). The findings are consistently neutral across every major clinical endpoint examined, including mortality, reinfarction, and bleeding.
What Was Studied
This meta-analysis investigated whether performing non-culprit lesion percutaneous coronary intervention (PCI) during the same index procedure — immediate complete revascularization — produces better or worse outcomes compared with deferring that intervention to a later date — staged complete revascularization — in patients presenting with STEMI and multivessel coronary artery disease. The primary outcome of interest was death from cardiac causes assessed at a median follow-up of 12 months, with secondary endpoints covering a broad spectrum of adverse clinical events.
How It Was Studied
This was a systematic meta-analysis of randomized controlled trials, incorporating an updated search of MEDLINE, Scopus, and EMBASE through September 2025, including data from the recently published OPTION-STEMI trial. Six eligible trials were identified, collectively enrolling 2,837 patients: 1,441 assigned to immediate complete revascularization and 1,446 to staged complete revascularization, both using drug-eluting stents. The study population comprised adults with STEMI and documented multivessel coronary artery disease who were undergoing primary PCI. All outcomes were evaluated at a median follow-up of 12 months, with staged revascularization defined as non-culprit PCI performed after the acute index event rather than at the time of primary intervention.
What Was Observed
- Cardiac death was equivalent between strategies: The rate of death from cardiac causes at 12 months was virtually identical in the two groups, with no statistically significant difference and near-unity effect size (RR 0.99, 95% CI 0.98–1.01; P = 0.33). This narrow confidence interval suggests the absence of a meaningful treatment effect rather than simply an underpowered null result.
- All-cause mortality and nonfatal MI were also comparable: Neither all-cause mortality (RR 0.99, 95% CI 0.97–1.00; P = 0.13) nor recurrent nonfatal myocardial infarction (RR 1.01, 95% CI 0.99–1.04; P = 0.17) differed between the two revascularization strategies, reinforcing the overall neutral picture for hard clinical endpoints.
- Safety outcomes showed no significant differences: Major bleeding risk was essentially the same between groups (RR 1.01, 95% CI 0.99–1.03; P = 0.21), as were stroke (RR 1.00, 95% CI 0.99–1.01; P = 0.75) and acute kidney injury (RR 1.00, 95% CI 0.99–1.03; P = 0.79), indicating that neither approach carries an identifiable procedural safety disadvantage.
- A non-significant trend favored immediate revascularization for unplanned procedures: Immediate complete revascularization was associated with a directional but statistically non-significant reduction in unplanned revascularization events compared with staged PCI (RR 0.97, 95% CI 0.93–1.01; P = 0.09), which does not meet the threshold for a confirmed finding but may warrant attention in future larger analyses.
Why This Matters
Complete revascularization is already recommended for STEMI patients with multivessel disease, but the optimal timing of treating non-culprit lesions has remained a point of clinical debate. This updated meta-analysis, now incorporating the OPTION-STEMI trial, provides the most current pooled evidence comparing both timing strategies and finds no outcome advantage for either approach across cardiac death, reinfarction, or safety endpoints. The results suggest that clinical decision-making regarding timing may appropriately be guided by patient- and procedural-level factors rather than a universal preference for one strategy.
How to Read This Result
While the meta-analysis is based on six randomized trials and demonstrates consistently narrow confidence intervals — supporting the reliability of the neutral conclusion — potential variability across trials in the precise definition and duration of the staging interval, as well as patient selection criteria, introduces residual uncertainty, and the 12-month follow-up horizon may not capture longer-term divergence between strategies.
Limitations
The abstract does not explicitly report study limitations.