Immediate Versus Staged Complete Revascularization in Multivessel Disease and STEMI: A Meta-Analysis of Randomized Trials.
Daniel O'Callaghan, Himanshu Rai, Daniele Giacoppo et al.
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In 30 seconds
This frequentist meta-analysis of four multicentre randomised trials compared immediate with staged complete revascularization in 2,651 patients with STEMI and multivessel disease. At 1 year, immediate revascularization was associated with higher all-cause mortality (HR: 1.50; 95% CI: 1.02-2.21; P = 0.04). It reduced recurrent MI under trial-specific definitions that included procedural MI, but not spontaneous MI; cardiac death and unplanned revascularization were comparable. The authors caution that the mortality result is statistically fragile, with relatively few deaths, and do not support an immediate strategy based on these findings.
Key findings
- At 1 year, all-cause mortality was higher with immediate complete revascularization (HR: 1.50; 95% CI: 1.02-2.21; P = 0.04).
- Immediate revascularization reduced recurrent MI using definitions that included procedural MI (HR: 0.58; 95% CI: 0.36-0.94; P = 0.02), but not spontaneous MI.
- Cardiac death and unplanned revascularization risks were comparable between immediate and staged strategies.
Why it matters
The analysis highlights that timing of nonculprit intervention may involve different outcome trade-offs: fewer recurrent MIs under definitions including procedural events, but a possible increase in 1-year all-cause mortality. The mortality estimate is uncertain because deaths were relatively few and the finding was statistically fragile, so the results warrant cautious interpretation rather than a definitive conclusion about comparative safety.
What to keep in mind
The mortality finding is based on relatively few deaths across four trials and is statistically fragile; prediction intervals also include no effect.