Complete Percutaneous Revascularization in Patients Presenting With ST‐Segment Myocardial Infarction Who Have Multivessel Coronary Disease: A Meta‐Analysis of Randomized Trials

Background: In patients presenting with ST‐segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD), the benefit of complete revascularization (CR) with respect to hard endpoints (death or myocardial infarction [MI]) and the role of invasive physiological assessment remains uncertain. Methods: This systematic review and meta‐analysis included randomized trials comparing CR with culprit only revascularization (COR) or immediate versus delayed CR in patients with STEMI and MVD. Random‐effects meta‐analysis was performed comparing clinical outcomes in individual groups. The primary endpoint was the composite of death or MI. Results: Sixteen trials were identified including a total of 15,160 patients. Compared to a COR strategy, CR significantly reduced the risk of death/MI (RR: 0.68, CI = 0.54–0.85). Angiography‐guided CR significantly reduced the risk of death/MI compared to a COR approach (RR: 0.57, CI = 0.40–0.83, p < 0.05). Seven trials evaluated physiology‐guided CR and did not demonstrate a significant difference for death/MI compared to a COR approach (RR: 0.74, CI = 0.54–1.01, p = 0.06). Meta‐regression showed that age was significantly associated with death/MI ( p = 0.026), and the timing of CR was associated with a reduced risk of ischemia‐driven revascularization ( p = 0.045). Conclusion: CR was associated with a lower risk of death or MI compared to COR. Compared to COR, angiography‐guided CR was associated with a lower incidence of death or MI; however, these benefits were not observed in the physiology‐guided CR group. There is a need for further head‐to‐head studies investigating the role of physiology‐guided risk‐stratification of nonculprit stenoses.