This study provides a detailed meta-analysis comparing immediate versus staged complete revascularization (CR) in patients with ST-elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD). The analysis addresses a critical clinical question: whether non-culprit vessel intervention should occur immediately during the primary percutaneous coronary intervention (PCI) or be staged later in subsequent procedures. The timing of CR remains uncertain, and this study synthesizes existing data to evaluate outcomes.
Background and Rationale:
STEMI patients often present with multivessel CAD, which increases the risk of major adverse cardiovascular events (MACE). While primary PCI focuses on restoring blood flow in the culprit lesion, evidence supports the benefits of CR for improved long-term outcomes. However, conflicting results exist regarding whether CR should be immediate or staged. Immediate CR reduces the number of interventions but raises concerns about longer procedure duration and potential complications like acute kidney injury (AKI). Staged CR, performed later in the hospital stay or after discharge, allows for patient stabilization but may expose non-culprit lesions to ischemic events during the delay.
Methods:
This meta-analysis adhered to PRISMA guidelines and included randomized controlled trials (RCTs) comparing immediate and staged CR in STEMI patients. Five RCTs, comprising 1,415 patients (703 immediate CR, 712 staged CR), were identified through systematic searches of MEDLINE, Embase, and Cochrane CENTRAL. Trials were required to report outcomes, including MACE, all-cause mortality, myocardial infarction (MI), unplanned ischemia-driven revascularization, and procedural complications like stent thrombosis. Data were pooled and analyzed using a random-effects model.
Findings:
- MACE and Mortality: Both strategies demonstrated comparable MACE rates. Immediate CR had a MACE incidence of 9.8%, while staged CR had 13.3% (RR: 1.07; 95% CI: 0.62-1.83). All-cause mortality rates were similar (3% for staged vs. 4.55% for immediate, RR: 0.70; 95% CI: 0.41-1.21). Cardiovascular mortality also showed no significant difference between the two groups.
- Myocardial Infarction: Recurrent MI was slightly more frequent in the staged group (4.5% vs. 2.6% in immediate CR, RR: 1.43), but this difference was not statistically significant.
- Unplanned Revascularization: A key finding was the significantly higher rate of unplanned ischemia-driven revascularization in the staged group (8.6% vs. 4.4%; RR: 1.92; 95% CI: 1.21-3.04). This highlights the risk of delaying treatment of non-culprit lesions, which may progress to ischemia during the interval.
Timing of Staged CR:
The timing of staged procedures varied widely across the included trials, ranging from 2.5 to 56 days post-STEMI. Notably, data suggest that performing staged CR within 10 days of the index PCI yields outcomes similar to immediate CR. Delays beyond 10 days were associated with increased adverse events, particularly unplanned revascularization.
Procedural Complications and Safety:
Concerns about procedure-related risks, such as acute kidney injury (AKI), were unfounded in this analysis. The incidence of AKI was low in both groups, with no significant differences reported. Similarly, stent thrombosis rates were comparable, indicating that immediate CR does not increase the risk of thrombotic complications despite longer procedure times.
Clinical Implications:
This meta-analysis highlights key considerations for clinicians managing STEMI patients with multivessel CAD. While immediate and staged CR offer comparable MACE and mortality outcomes, delaying revascularization can increase the risk of unplanned ischemic events. To mitigate this risk, staged CR should be performed early, ideally within the same hospitalization or no later than 10 days post-PCI. These findings align with emerging evidence from recent large trials like MULTISTARS AMI and BIOVASC, which emphasize the importance of timely intervention.
Limitations:
This analysis has several limitations. The timing of staged CR varied significantly across studies, which may have influenced outcomes. Additionally, MACE definitions differed slightly among trials, introducing potential variability. The study sample size was insufficient for robust conclusions on some endpoints, underscoring the need for further large-scale trials.
Conclusion:
Immediate and staged CR provide comparable outcomes for MACE, mortality, and MI in STEMI patients with multivessel CAD. However, staged CR is associated with a higher rate of unplanned revascularization, particularly when delayed beyond 10 days. Early staged intervention, within the same hospitalization, may strike a balance between safety and efficacy, optimizing patient outcomes. Future research should focus on defining precise timing for staged CR to guide clinical practice further.
