Myocardial infarction and multivessel disease: a network meta-analysis comparing complete functional, angiography-guided and culprit only revascularization

The optimal percutaneous coronary intervention (PCI) revascularization strategy in patients presenting with multi-vessel (MV) coronary artery disease (CAD) and acute myocardial infarction (MI) has not been systematically addressed. Accordingly, we performed a frequentist network meta-analysis with the aim of assessing the prognostic impact of different PCI strategies. We conducted an electronic research for studies including angiography-guided and functional-guided complete revascularization in patients with acute MI from 2001 to 30th November 2023. Endpoints of interest were cardiovascular mortality, all-cause mortality, spontaneous MI and any revascularization. Twelve randomized clinical trials involving 11,581 patients fulfilled the inclusion criteria. Functional-guided complete PCI was associated with lower cardiovascular death compared to culprit-only PCI (incidence rate ratio [IRR] 0.61, 95% confidence interval [CI] 0.39-0.96; P=0.033). Both complete functional- and angio-guided PCI reduced the risk of further revascularization compared to culprit-only PCI (IRR 0.37, 95% CI 0.24-0.55, P<0.001, and IRR 0.33, 95% CI 0.20-0.52, P<0.001, respectively). Both complete functional- and angio-guided PCI resulted in a non-significant reduction of spontaneous MI compared to culprit-only PCI strategy (IRR 0.76, 95% CI 0.50-1.15; P=0.20 and IRR 0.72, 95% CI 0.47-1.12; P=0.15, respectively). No significant differences were found regarding other study endpoints and other comparisons. In patients with MI and MV CAD, undergoing successful PCI of IRA, a complete revascularization strategy, regardless of the specific approach, was associated with a lower incidence of repeat revascularization compared with a culprit-only strategy. Complete functional-guided revascularization resulted in lower incidence of cardiovascular death, whereas a complete angio-guided approach did not show the same benefit.