Timing Is Everything — Evidence for When to Perform Complete Revascularization in STEMI

: This NEJM editorial reviews the evolving evidence around complete revascularization in patients with STEMI and multivessel coronary artery disease, focusing on the MULTISTARS AMI trial. Historically, timing strategies immediate vs. staged PCI for non-infarct-related lesions have been debated. MULTISTARS randomized 840 patients at 37 European centers to either immediate complete revascularization at index PCI or staged PCI within 19–45 days. At 1 year, the immediate strategy reduced the composite endpoint (death, MI, stroke, unplanned revascularization, or heart failure hospitalization) from 16.3% to 8.5%, driven by fewer procedure-related MIs and ischemia-driven interventions. However, no difference was seen in spontaneous MI or mortality. Inclusion of procedure-related events and angina-driven revascularization complicates interpretation. The editorial calls for a larger, definitive trial incorporating lesion complexity, infarct burden, physiological testing, and patient-centered factors (e.g. age, renal function, intravascular imaging) to guide optimal timing of PCI.

: This NEJM editorial reviews the evolving evidence around complete revascularization in patients with STEMI and multivessel coronary artery disease, focusing on the MULTISTARS AMI trial. Historically, timing strategies immediate vs. staged PCI for non-infarct-related lesions have been debated. MULTISTARS randomized 840 patients at 37 European centers to either immediate complete revascularization at index PCI or staged PCI within 19–45 days. At 1 year, the immediate strategy reduced the composite endpoint (death, MI, stroke, unplanned revascularization, or heart failure hospitalization) from 16.3% to 8.5%, driven by fewer procedure-related MIs and ischemia-driven interventions. However, no difference was seen in spontaneous MI or mortality. Inclusion of procedure-related events and angina-driven revascularization complicates interpretation. The editorial calls for a larger, definitive trial incorporating lesion complexity, infarct burden, physiological testing, and patient-centered factors (e.g. age, renal function, intravascular imaging) to guide optimal timing of PCI.