Complete versus culprit-only revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease: a meta-analysis of randomized trials

The best strategy for the treatment of the non-infarct artery in patients with ST-elevation myocardial infarction (STEMI) and multivessel disease (MVD) undergoing primary percutaneous coronary intervention (PCI) is not yet defined.

We searched the literature for randomized controlled trials (RCTs) that compared complete revascularization (CR) with infarct-related coronary artery (IRA) only revascularization in hemodynamically stable patients with STEMI. Random effect risk ratios (RRs) were calculated for clinical outcomes.

Nine RCTs with 2989 patients were included. No significant difference in all-cause mortality emerged between CR and IRA-only groups (relative risk [RR] = 0.74; 95% confidence interval [CI]: 0.52 to 1.04; p = 0.08). Compared with IRA-only, CR was associated with significantly lower rates of major adverse cardiac events (MACE) (RR = 0.53; 95% CI: 0.41 to 0.68; p < 0.001), cardiac death (RR = 0.48; 95% CI: 0.29 to 0.79; p = 0.004) and repeat revascularization (RR = 0.38; 95% CI: 0.30 to 0.47; p < 0.001). In subgroups analysis, immediate complete revascularization (ICR) reduced the risk of all-cause mortality (RR = 0.62; 95% CI: 0.39 to 0.97; p = 0.04), whereas staged complete revascularization (SCR) did not show any significant benefit in all-cause mortality (RR = 0.92; 95% CI: 0.46 to 1.86; p = 0.82). Stroke, contrast-induced nephropathy and major bleeding were not different between CR and IRA-only.

For patients with STEMI and multivessel disease undergoing primary PCI, complete revascularization did not decrease the risk of all-cause mortality in current evidence from randomized trials. When feasible, immediate complete revascularization might be considered in patients with STEMI and multivessel disease.