Timing of revascularization for non-culprit lesions in ST-segment elevation myocardial infarction with multivessel disease: a meta-analysis of randomized controlled trials

Background Multivessel coronary artery disease (CAD) is frequently observed in patients with ST-segment elevation myocardial infarction (STEMI). However, the optimal timing for complete revascularization remains a subject of ongoing debate. This study aimed to compare major adverse cardiovascular events (MACE) and other clinical outcomes between immediate complete revascularization (ICR) and staged complete revascularization (SCR). Methods A systematic review and meta-analysis of randomized controlled trials (RCTs) comparing ICR and SCR in patients with STEMI and multivessel CAD was performed. The main outcome was MACE, and the secondary outcomes included all-cause death, cardiac death, myocardial infarction (MI), and unplanned revascularization (UR). Results A total of seven RCTs (n = 3,017; mean follow-up, 1.06 years) were included in this meta-analysis. Baseline characteristics included mean age, 58.6–66.0 years; male patients, 62.3%–83.0%; diabetes mellitus, 13.8%–42.0%; and hypertension, 40.0%–94.0%. No significant difference in MACE was detected between the ICR and SCR groups (10.3% vs. 11.4%; risk ratio (RR) 0.96; 95% CI 0.67–1.37; p = 0.81). Similarly, the rates of cardiac death and UR were not significantly different. ICR was associated with a higher rate of all-cause mortality (5.0% vs. 3.4%; RR 1.45; 95% CI 1.02–2.05; p = 0.04). Conversely, SCR exhibited a significantly higher incidence of MI (2.8% vs. 4.4%; RR 0.64; 95% CI 0.41–0.99; p = 0.04). Conclusions While MACE rates were comparable between ICR and SCR, secondary endpoint analyses revealed that ICR was associated with a higher rate of all-cause mortality and SCR was associated with a higher risk of MI, warranting cautious interpretation. Staged revascularization may help balance ischemic risk reduction with procedural safety in selected patients with STEMI and multivessel disease.