Early Complete Revascularization in Hemodynamically Stable Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Disease

Background: The optimal strategy and timing of revascularization in hemodynamically stable patients with ST-segment elevation myocardial infarction and multivessel disease is unknown. We performed a systematic review and meta-analysis to explore the comparative efficacy and safety of early complete revascularization vs culprit-only or staged revascularization in this setting. Methods: We searched the literature for randomized clinical trials that assessed this issue. Early complete revascularization was defined as a complete revascularization achieved during the index procedure or within 72 hours. Efficacy outcomes were major adverse cardiovascular events, myocardial infarction, repeat revascularization, and all-cause mortality. Safety outcomes were all bleeding events, stroke, and contrast-induced acute kidney injury. Results: Nine randomized clinical trials with a total of 2837 patients were included; 1254 received early complete revascularization and 1583 were treated with other revascularization strategies. After a mean follow-up of 15.3 ± 9.4 months early complete revascularization was associated with a lower risk of major adverse cardiovascular events (relative risk [RR], 0.51; 95% confidence interval [CI], 0.41-0.62; P < 0.00001; number needed to treat = 8), myocardial infarction (RR, 0.59; 95% CI, 0.40-0.87), and repeat revascularization (RR, 0.39; 95% CI, 0.28-0.55) without any difference in all-cause mortality and in safety outcomes compared with culprit-only or staged revascularization. Moreover, fractional flow reserve-guided complete revascularization reduced the incidence of repeat revascularization compared with angiography-guided procedure (χ² = 4.36; P = 0.04). Conclusions: Early complete revascularization should be considered in hemodynamically stable patients with ST-segment elevation myocardial infarction and multivessel disease deemed suitable for percutaneous interventions. Fractional flow reserve-guided complete revascularization might be superior to angiography-guided procedures in reducing need for further interventions.