Optimal timing of complete revascularization in patients presenting with STEMI and multivessel disease: a systematic review and meta-analysis

Introduction

Multivessel coronary artery disease is widely common among patients presenting with ST-elevation myocardial infarction (STEMI). Percutaneous coronary intervention is deemed as the gold standard for the therapy of STEMI.1 This addresses the goal of revascularization of the infarct related artery as soon as possible. However, the optimal timing for complete revascularization of the non-infarct related artery is unclear. The aim of this study is to use evidence from published randomized controlled trials (RCT) to compare staged complete revascularization (SR) and immediate complete revascularization (IR) in terms of safety.

Methods

We followed the PRISMA statement guidelines. We searched multiple online databases. We included studies comparing SR to IR in terms of all-cause mortality, major adverse cardiac events (MACE), non-fatal myocardial infarction (MI), spontaneous MI and unplanned ischemia-driven revascularization (UIDR). We conducted leave-one-out analysis and meta-regression according to timing of SR (in-hospital vs post-discharge).

Results

7 RCTs (3,017 total patients) were included.2-8 The SR group was favored in terms of all-cause mortality (RR = 0.67, 95% CI = 0.48 - 0.93; t(6) = −2.97, p = 0.025). No statistically significant differences were found between the two groups in terms of MACE, UIDR and spontaneous MI. In terms of non-fatal MI, the IR group was favored (RR = 1.74; 95% CI = 1.03 - 2.95; p = 0.04). There was a significantly higher risk of procedure related MI in the SR compared to the IR group (RR = 3.77; 95% CI = 1.60 - 8.94; p = 0.02).

In our meta-regression, no statistically significant difference was found between the early timing of the staged procedure and the IR group in all outcomes. However, late timing of the staged procedure was associated with worse outcomes in MACE (RR = 1.51, 95% CI = 1.10 – 2.07), non-fatal MI (RR = 2.74, 95% CI = 1.63 - 4.62; p = 0.004) and UIDR (RR = 1.75; 95% CI = 1.19 - 2.59; p = 0.015). Late timing of the staged procedure was not associated with a significant difference in all-cause mortality.

Lastly, Bayesian meta-regression revealed that each doubling of the median duration of delay between PPCI and the staged procedure was associated with a 15% increase in the MACE risk ratio (RR per doubling = 1.15; 95% CrI = 0.91 - 1.43) with a >90% posterior probability that longer delays worsen outcomes.

Conclusion

A significant difference was found favoring SR in all-cause mortality over IR. Early timing was associated with comparable to or better outcomes than IR. Late timing of the staged procedure was associated with a greater risk of events in nearly all outcomes.