STEMI with multivessel disease: staging non-culprit PCI may be the safer timing

Design

Meta-analysis of 4 multicentre randomised trials

Population

2,651 patients with STEMI and multivessel disease

Primary outcome

All-cause death at 1 year

Effect

HR 1.50 (95% CI 1.02–2.21) for immediate vs staged complete revascularisation; I² = 0%

Complete revascularisation is recommended for STEMI with multivessel disease; the open question is timing. This meta-analysis pooled four multicentre randomised trials, 2,651 patients in all, that compared treating non-culprit lesions during the index procedure with doing so at a staged procedure, using only newer-generation drug-eluting stents and at least a year of follow-up.

All-cause death at one year was higher with immediate complete revascularisation (HR 1.50, 95% CI 1.02–2.21), with no heterogeneity between trials. Immediate treatment reduced recurrent MI as defined by trial protocols (HR 0.58), but that advantage came from procedural MI; spontaneous MI did not differ (HR 0.91, 95% CI 0.55–1.48). Cardiac death and unplanned revascularisation were similar.

The authors call the mortality result fragile: deaths were few and the prediction interval runs from 0.80 to 2.81. Even so, the data give no support for routinely doing everything at the index procedure. Guidelines allow either timing and have not changed; within them, staging during the admission or soon after looks the sounder default. Cardiogenic shock was not part of these trials and is managed differently.

• Favour staging non-culprit PCI in stable STEMI with multivessel disease.
• Do not use a lower recurrent MI rate with immediate PCI as a reason to choose it; it reflected procedural MI.
• Ensure the staged procedure is booked before discharge so complete revascularisation actually happens.
• These trials did not include cardiogenic shock, where culprit-only PCI at the index procedure is standard.
• Discuss timing with the patient as part of the plan, not as an afterthought.

Why it matters

Immediate complete revascularisation has been gaining ground for convenience, and pooled randomised data now hint that it may cost lives.

Don't overread it

The mortality finding rests on few deaths and its prediction interval crosses 1, so it is a warning rather than proof of harm.

The statistics, in plain English

A hazard ratio of 1.50 means deaths were about half as frequent again with immediate PCI. The confidence interval only just excludes 1 (lower bound 1.02), and the prediction interval — the range expected in a new trial — crosses 1, so a future trial could find no difference.

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