Immediate vs staged in-hospital vs staged out-of-hospital complete revascularization in STEMI patients with multivessel disease: a network meta-analysis of randomized trials

Background In ST-segment elevation myocardial infarction (STEMI) with multivessel coronary artery disease (MVD), the optimal timing of complete revascularization (CR)—whether during the index procedure, staged in-hospital, or deferred after discharge—remains debated, with implications for clinical practice. Methods We systematically searched PubMed and EMBASE through September 2025 for randomized controlled trials (RCTs) assessing outcomes of different CR timings in STEMI with MVD. Pairwise meta-analysis compared immediate versus staged CR, whereas network meta-analysis (NMA) evaluated immediate, staged in-hospital, and staged out-of-hospital CR. The primary endpoint was major adverse cardiovascular events (MACE). Secondary endpoints included all-cause death, cardiovascular (CV) death, recurrent myocardial infarction (MI), and repeat revascularization. Results Eleven studies (9 RCTs and 2 prespecified sub-analyses; 5,483 patients) were included. In pairwise analysis, MACE did not differ between immediate and staged CR (OR 0.90, 95% CI 0.64–1.25; p= 0.54). Immediate CR was associated with higher all-cause mortality (OR 1.46, 95% CI 1.02–2.09; p= 0.039) but fewer recurrent MIs, including type 4a (OR 0.64, 95% CI 0.43–0.94; p= 0.025). No differences were observed for exploratory endpoints. In the NMA, comparisons among the three strategies revealed no significant differences in MACE, all cause death and CV death. For recurrent MI, both immediate CR (OR 0.53, 95% CI 0.32–0.85; p = 0.01) and staged in-hospital CR (OR 0.69, 95% CI 0.48–0.98; p = 0.04) were associated with lower risk compared with staged out-of-hospital CR. Similarly, for repeat revascularization, immediate CR (OR 0.53, 95% CI 0.35–0.82; p = 0.003) and staged in-hospital CR (OR 0.52, 95% CI 0.32–0.85; p = 0.01) showed significantly lower risks versus staged out-of-hospital CR. Bayesian ranking (SUCRA) identified staged in-hospital CR as the most effective strategy for reducing MACE, all-cause death, and CV death, whereas staged out-of-hospital CR ranked worst for MACE, recurrent MI, and repeat revascularization. Conclusions Staged in-hospital CR provides the most favorable balance of efficacy and safety in STEMI with MVD, outperforming staged out-of-hospital CR and demonstrating comparable outcomes to immediate CR. Larger, adequately powered RCTs are warranted to define the optimal revascularization timing.