Immediate versus staged PCI in STEMI and multivessel disease: a systematic review and meta-analysis

Introduction and objectives:To compare clinical outcomes of immediate vs staged multivessel percutaneous coronary intervention (PCI) for non-culprit lesions in hemodynamically stable patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease. Methods:We conducted this systematic review and meta-analysis according to PRISMA guidelines.PubMed, Embase, and Cochrane databases were searched throughout September 2025.Outcomes included cardiac death, all-cause mortality, reinfarction, acute kidney injury, and stroke.Risk ratios were calculated, and trial sequential analysis, incidence rate ratio (IRR) analyses, and meta-regression were conducted.Results: Six randomized controlled trials including 4267 patients were analyzed.At the 1-year follow-up, there were no significant differences between immediate and staged PCI regarding cardiac death (RR, 1.26; 95%CI, 0.89-1.79),all-cause mortality (RR, 1.18; 95%CI, 0.93-1.50),acute kidney injury (RR, 0.91; 95%CI, 0.64-1.31),or stroke (RR, 1.17; 95%CI, 0.66-2.05).Immediate PCI was associated with a lower risk of reinfarction (RR, 0.63; 95%CI, 0.40-0.98),a finding confirmed by IRR analysis (IRR, 0.60; 95%CI, 0.39-0.94;I 2 = 0%).Exploratory meta-regression analyses did not identify procedural timing or baseline comorbidities as significant effect modifiers.Conclusions: In patients with ST-segment elevation myocardial infarction and multivessel disease, immediate PCI was associated with a lower risk of reinfarction, without any significant differences being reported in cardiac death or all-cause mortality compared with staged PCI.Although trial sequential analysis indicates that current evidence remains underpowered for certain outcomes, the consistency of findings across multiple analytical approaches supports the safety profile of immediate complete revascularization, pending confirmation in adequately powered randomized trials.(PROSPERO: CRD42023485163.I).