Non-Culprit Vessel Revascularization Strategies in Acute Myocardial Infarction With Multivessel...

INTRODUCTION The optimal nonculprit revascularization strategy in acute myocardial infarction (AMI) with multivessel disease (MVD) remains uncertain. Established approaches include physiology- and angiography-guided complete revascularization, while deferred non-invasive ischemia-guided management offers a conservative alternative. The comparative effectiveness of these strategies remains unclear. Research QUESTION What is the comparative effectiveness of physiology-guided, angiography-guided, and deferred ischemia-guided revascularization strategies in patients with AMI and MVD? METHODS Embase, Scopus, Cochrane, and PubMed were searched through March 2026 for randomized controlled trials (RCTs) evaluating nonculprit-vessel management strategies in AMI with MVD following successful culprit-lesion PCI. Eligible studies were categorized into six nodes: immediate physiology-guided PCI (Imm-Phys), staged physiology-guided PCI (Stg-Phys), immediate angiography-guided PCI (Imm-Ang), staged angiography-guided PCI (Stg-Ang), Deferred non-invasive ischemia-guided strategy (DIG), and culprit-only PCI. A frequentist random-effects network meta-analysis pooled odds ratios (ORs) with 95% confidence intervals (CIs), and treatments were ranked using P-scores. ResultS A total of 23 RCTs (including 17,020 patients) were analyzed. For all-cause mortality, none of the strategies reached statistical significance; however, DIG showed the most favorable estimate versus culprit (OR 0.29), followed by Imm-Phys (OR 0.66) and Imm-Ang (OR 0.67), with DIG ranking highest (P-score 0.8049). Imm-Ang showed the greatest significant reduction in myocardial infarction (OR 0.34, 95% CI 0.23–0.49) and major adverse cardiovascular events (OR 0.32, 95% CI 0.20–0.50), ranking first for both (P-scores 0.9772 and 0.9726). Imm-Phys was the only strategy associated with significant reductions in cardiac death (OR 0.58, 95% CI 0.37–0.90) and heart failure (HF) hospitalization (OR 0.60, 95% CI 0.38–0.94), and ranked highest for HF hospitalization (P-score 0.9157). All strategies reduced repeat revascularization compared with culprit, with the greatest effect seen with Imm-Ang (OR 0.16).). No significant differences were observed for stroke, contrast-induced nephropathy, major bleeding, non-cardiovascular death, or target vessel failure. Stg-Phys was associated with increased stent thrombosis risk (OR 2.81, 95% CI 1.17–6.72). Conclusion In AMI with MVD, Imm-Ang PCI greatly reduced ischemic events and repeat revascularization, while Imm-Phys PCI was the only strategy associated with significantly reduced cardiac death and HF hospitalization. DIG PCI showed favorable mortality trends but was imprecise. Overall, immediate complete revascularization strategies appear most effective, although may carry safety concerns.