Immediate versus staged complete revascularization in patients with acute coronary syndrome: a systematic review and meta-analysis of randomized controlled trials

A strategy of complete revascularization (CR) is recommended in patients with acute coronary syndrome (ACS) and multivessel disease (MVD). However, the optimal timing of CR remains equivocal. We searched MEDLINE, Embase, the Cochrane Library, and ClinicalTrials.gov for randomized controlled trials (RCTs) comparing immediate CR (ICR) with staged CR (SCR) in patients with ACS and MVD. Our primary outcomes were all-cause and cardiovascular mortality. All outcomes were assessed at three time points: in-hospital or at 30 days, at 6 months-1 year, and at > 1 year. Data were pooled in RevMan 5.4 using risk ratio (RR) as the effect measure. A total of 9 RCTs (7506 patients) were included in our review. Seven trials enrolled ST-segment elevation myocardial infarction (STEMI) patients, one enrolled non-STEMI patients only, and one enrolled patients with all types of ACS. There was no difference between ICR and SCR regarding all-cause and cardiovascular mortality at any time window. ICR reduced the rate of myocardial infarction (MI) and decreased the rate of repeat revascularization at 6 months and beyond. The rates of cerebrovascular events and stent thrombosis were similar between the two groups. In conclusion, the current meta-analysis demonstrated a lower rate of MI and a reduction in repeat revascularization at and after 6 months with ICR strategy in patients with mainly STEMI and MVD. The two groups had no difference in the risk of all-cause and cardiovascular mortality. Further RCTs are needed to provide more definitive conclusions and investigate complete revascularization strategies in other ACS.