Complete percutaneous revascularization in stemi patients with multivessel disease: a meta-analysis and meta-regression of contemporary randomized trials.

Abstract

Background In patients presenting with ST-segment elevation myocardial infarction (STEMI) and multivessel disease, the benefit of complete revascularization (CR) with respects to hard endpoints (death or myocardial infarction (MI)) remains uncertain. Furthermore, the role of invasive physiological assessment with fractional flow reserve and quantitative flow ratio in evaluating non-culprit lesion severity remains unclear. Methods This systematic review and meta-analysis included the totality of randomized clinical trials comparing CR with culprit lesion only revascularization (COR) or immediate versus delayed CR in patients with STEMI and multivessel disease. Random-effects meta-analysis was performed comparing clinical outcomes in individual groups. The primary endpoint was the composite of death or MI. Results Sixteen randomized clinical trials were identified including a total of 15,160 patients, of which eleven trials evaluated CR versus COR. Compared with a COR strategy, CR significantly reduced the risk of death/MI (RR 0.68, CI = 0.54 - 0.85). Angiographic guided CR significantly reduced the risk of death/MI compared to a COR approach (RR 0.57, CI = 0.40 - 0.83, P<0.05). Seven trials evaluated physiology guided CR with fractional flow reserve or quantitative flow ratio and did not demonstrate a significant difference for death/MI compared to a COR approach (RR 0.74, CI = 0.54 - 1.01, p=0.06). Meta regression showed that age was significantly associated with Death/MI (p=0.026) and the timing of CR was associated with a reduced risk of ischemia driven revascularization (p=0.045). Conclusion CR was associated with a lower risk for death or MI compared with COR. Compared to COR, angiographically-guided CR was associated with a lower incidence for death or MI, however these benefits were not observed in the physiology guided CR group. There is a need for further head to head studies investigating the role of physiology guided risk-stratification of non-culprit stenoses.Copyright © 2025 American College of Cardiology Foundation