Early versus delayed complete revascularisation in patients presenting with ST-segment elevation myocardial infarction and multivessel disease: a systematic review and meta-analysis of randomised controlled trials

Abstract

Background: Several studies have demonstrated that complete revascularisation improves clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary disease. However, the optimal timing of non-culprit lesion revascularisation remains controversial.

Objective: The aim of this systematic review and meta-analysis was to assess the effect of timing of complete revascularisation on cardiovascular outcomes in patients with STEMI and multivessel coronary artery disease.

Methods: Searches of PubMed, the Cochrane Library, ClinicalTrials.gov and the reference lists of relevant papers were conducted covering the period from 2004 to 2019. A pairwise analysis was performed to compare the difference in clinical outcome between early complete revascularisation (index procedure or index hospitalisation) and delayed complete revascularisation (after discharge) in patients with STEMI.The primary endpoint was the incidence of major adverse cardiac events (MACE), which was defined as the composite of all-cause mortality, recurrent myocardial infarction, unplanned repeated revascularisation and cardiovascular death.

Results: Twelve studies including a total of 7596 patients were identified. The MACE rate was 10.37% in early complete revascularisation compared with 18.17% in culprit only (p=0.01). When complete revascularisation was delayed, the MACE rate was 11.81% after complete revascularisation compared with 17.21% in culprit-only percutaneous coronary intervention (PCI) (p=0.01). A meta-regression analysis demonstrated no relationship between timing of complete revascularisation and reduction in MACE relative to culprit-only PCI (p=0.862).

Conclusion: In patients with STEMI treated by primary PCI and multivessel disease, there is a benefit of complete revascularisation over culprit-only PCI whether non-culprit revascularisation is performed early in hospital or delayed as an elective procedure. We have not demonstrated a relationship between timing of complete revascularisation and MACE.

Prospero registration number: CRD42021226789.

Keywords: Cardiac Catheterization; Myocardial Infarction; Percutaneous Coronary Intervention.

Figure 1

Search strategy and study selection.

Figure 2

Forest plot of comparison between early complete revascularisation versus culprit lesion-only PCI. PCI, percutaneous coronary intervention.

Figure 3

Forest plot of comparison between delayed complete revascularisation and culprit lesion-only PCI. PCI, percutaneous coronary intervention.

Figure 4

Regression plot of relation between MACE rate and time to complete revascularisation. MACE, major adverse cardiac events; PCI, percutaneous coronary intervention.