What is the clinical evidence from this study?

Study design: RCT. Population: ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD) (n=840). Intervention: Immediate multivessel PCI vs. Staged multivessel PCI. Primary outcome: Composite of all-cause death, non-fatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure at 1 year (in Killip class I patients) (HR 0.40, 95% CI 0.25-0.65, p=< 0.01).

What question did this study set out to answer?

To assess outcomes of immediate versus staged multivessel PCI in STEMI patients with higher Killip class.

June 27, 2026Scientific Reports0 citationsOpen Access

Killip class at presentation and immediate versus staged multivessel PCI in patients with STEMI

Q: What are the key findings of this study?

Immediate multivessel PCI reduced the primary composite endpoint by 60% compared to staged PCI in patients with STEMI and Killip class I (HR 0.40), but this benefit was attenuated and not significant in patients with Killip class ≥II.

Q: What question did this study set out to answer?

To assess outcomes of immediate versus staged multivessel PCI in STEMI patients with higher Killip class.

PJPhilipp JakobInterventional Cardiology FVFerdinando VarbellaOspedale degli Infermi ALA LinkeTechnische Universität Dresden

Key Result

Immediate multivessel PCI reduced the primary composite endpoint by 60% compared to staged PCI in patients with STEMI and Killip class I (HR 0.40), but this benefit was attenuated and not significant in patients with Killip class ≥II.

Key Points

To assess outcomes of immediate versus staged multivessel PCI in STEMI patients with higher Killip class.
Conducted a subgroup analysis of the MULTISTARS AMI trial stratified by Killip classes.
Primary endpoint included all-cause death, non-fatal myocardial infarction, stroke, unplanned revascularization, or hospitalization for heart failure at 1 year.
Compared outcomes between patients with Killip class I and Killip class ≥ II.
The primary endpoint occurred in 17.9% of patients with Killip class ≥ II versus 11.4% with Killip class I (HR, 1.57; 95% CI, 0.92–2.70; p=0.11).
Immediate PCI reduced the primary endpoint in Killip class I patients (6.8% vs. 15.8%; HR, 0.40; 95% CI, 0.25–0.65; p<0.01).
No significant difference was observed in Killip class ≥ II (20.0% vs. 15.4%; HR, 1.37; 95% CI, 0.50–3.78; p=0.55).

Study Design

Type

RCT (n=840)

Blinding

Open-label

Randomization

1:1

Multicenter

Yes

Structured PICO

Does immediate multivessel PCI reduce adverse cardiovascular events compared to staged multivessel PCI in STEMI patients with multivessel disease presenting with different Killip classes?

Population

840 hemodynamically stable patients with STEMI and multivessel coronary artery disease, stratified by Killip class and followed for 1 year.

Intervention

Immediate multivessel percutaneous coronary intervention (PCI)

Comparator

Staged multivessel percutaneous coronary intervention (PCI)

Outcome

Composite of all-cause death, non-fatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure at 1 yearcomposite

The benefit of immediate multivessel PCI over staged PCI in STEMI patients with multivessel disease is significant in Killip class I but appears attenuated in those with Killip class ≥ II.

Main Result

Hazard Ratio: 0.4 (95% CI 0.25–0.65)

Absolute Event Rate: 6.8% vs 15.8%

p-value: p=< 0.01

Limitations

The subanalysis was not prespecified and should be interpreted as hypothesis generating.
The study was not adequately powered to detect differences in event rates between patients with Killip class I and Killip class ≥II.
The majority of patients presented with Killip class I, preventing definitive conclusions for patients with Killip class ≥II.
The timing of the staged procedure (median 37 days) may have contributed to the clinical benefit observed in the immediate PCI group.
Generalizability is limited because high-risk patients (e.g., cardiogenic shock, left main disease, chronic total occlusion) were excluded.
The diagnosis of PCI-related myocardial infarction remains challenging and may have resulted in underdetection in the immediate PCI group.

Abstract

Abstract Patients with ST-segment elevation myocardial infarction (STEMI) and higher Killip class are at an increased risk of death. We sought to assess outcomes of an immediate or staged multivessel percutaneous coronary intervention (PCI) in patients with higher Killip class presenting with STEMI and multivessel coronary artery disease (MVD). We conducted a subgroup analysis of the MULTISTARS AMI trial with stratification of patients according to Killip classes. Outcomes of patients with Killip class I and Killip class ≥ II were compared. The primary end point was a composite of all-cause death, non-fatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure at 1 year. The primary end point occurred in 15 (17.9%) patients with Killip class ≥ II and 78 (11.4%) patients with Killip class I (HR, 1.57 95%CI, 0.92–2.70, p-value = 0.11). Comparing an immediate with a staged multivessel PCI strategy, the immediate strategy reduced the primary endpoint in patients with Killip class I (6.8% vs. 15.8%; HR, 0.40 95%CI, 0.25–0.65, p-value < 0.01), whereas the difference was not significant in patients with Killip class ≥ II (20.0% vs. 15.4%; HR, 1.37 95%CI, 0.50–3.78, p-value = 0.55). There was a significant treatment-by-subgroup interaction for the primary endpoint (P interaction = 0.029), with immediate multivessel PCI not showing an advantage in Killip class ≥ II patients. Conclusively, in the MULTISTARS AMI trial, the benefit of immediate multivessel revascularization strategy observed in patients with Killip class I appeared attenuated in those presenting with Killip class ≥ II, suggesting a potential difference in treatment effect that warrants further investigation. (Supported by Boston Scientific; MULTISTARS AMI, NCT03135275)

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