A systematic search of MEDLINE, Scopus, and Cochrane was performed through November 2025 using keywords “ST segment elevation myocardial infarction,” “multivessel,” “complete revascularization,” “immediate revascularization,” and “staged revascularization” to identify RCTs that compared immediate CR versus staged CR in patients with STEMI and MVD. Further screening of ClinicalTrials.gov was performed to identify any relevant RCTs not retrieved through the primary search. Our meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines ( Supplemental Table S1 ).

We included RCTs that compared the outcomes between immediate CR versus staged CR in patients with STEMI and MVD. RCTs that enrolled mixed ACS populations were eligible if outcomes for the STEMI subgroup were reported separately. In such cases, only data from the STEMI subgroup were extracted. Nonrandomized studies were excluded. Studies were independently confirmed by 2 independent authors (W.H. and R.T.). The following data elements were extracted: study design, baseline patient characteristics, baseline procedural characteristics, intervention strategies, and clinical outcomes. Discrepancies among investigators were resolved by consensus.

The primary outcome was major adverse cardiovascular events (MACE). Secondary endpoints included all-cause mortality, cardiovascular mortality, recurrent myocardial infarction (MI), unplanned revascularization, stent thrombosis, as well as safety endpoints of stroke, major bleeding, and acute nephropathy. Outcomes were adopted as defined by the RCTs included in our analysis ( Supplemental Table S2 ). Sensitivity analyses were also performed for various validity assumptions, procedural specificities, and anatomic complexity.

The quality of the included RCTs was evaluated by 2 investigators (W.H. and R.T.) utilizing the Cochrane Risk of Bias 2 (RoB 2) assessment tool in RevMan (Cochrane Collaboration, Oxford, United Kingdom). Criteria included in the assessment were random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other sources of bias. Accordingly, RCTs were classified as low risk, unclear risk, or high risk of bias. Publication bias for the primary outcome was assessed by visual inspection of the funnel plot and Egger’s rest.

Data was pooled using random-effects model due to anticipated heterogeneity among included RCTs. The statistical method performed was the Mantel–Haenszel test. Heterogeneity was assessed via chi-squared and Higgin’s I ² test. Summary estimates were reported as risk ratios (RR) with corresponding 95% confidence interval reported by the Wald-type method. P -values were considered significant if <0.05. RevMan (Cochrane Collaboration, Oxford, United Kingdom) was utilized to perform statistical analysis.

The study flowsheet is outlined in Figure 1 . From our systematic search, 599 records were identified with 486 records screened after removing duplicates. After excluding records that did not meet our inclusion or exclusion criteria, 15 full-text articles were assessed for eligibility. From the 15 articles, 3 full-text articles were excluded as they were nonrandomized trials or did not exclusively study patients with STEMI. The final analysis included 11 RCTs ^,,,,,,,,,, with 4,472 patients assessed at a weighted mean follow-up of 18.5 months. Timing of staged CR was heterogeneous among the included RCTs, with 5 RCTs ^,,,, staging revascularization during the index admission, 2 ^, after hospital discharge, 2 ^, mixed during index admission or after hospital discharge, and 2 ^, were not reported ( Table 1 ). The weighted mean time to staged CR was approximately 32 days.

Study flowsheet.

A total of 4,472 patients were assessed: 2,251 in the immediate CR group and 2,221 in the staged CR group. Baseline characteristics of the individual RCTs and cumulative patients can be found in Table 2 . In summary, patients were predominantly male (79%) with an average age of 64 years and medical history significant for smoking (55%), hypertension (51%), hyperlipidemia (41%), diabetes mellitus (29%), and prior MI (12%). Specific details regarding the individual RCTs can be found in Supplementary Table S3 . Baseline procedural characteristics can be found in Table 3 . Five RCTs ^,,,, utilized varying degrees of intravascular imaging or physiology, 7 RCTs ^,,,,,, explicitly excluded left main (LM) disease, and 6 RCTs ^,,,,, exclusively utilized drug-eluting stents (DES).

Table 2

Baseline patient characteristics

Trial Name	Age	Male	HTN	HLD	DM	Previous MI	Smoking	LVEF
iMODERN (2025)	62.7 ± 11.3/ 62.7 ± 11	77.8%/ 77.6%	37.4%/ 39%	27.3%/ 30.8%	13.2%/ 15.4%	NR	69.2%/ 63.8%	NR/53 ± 9.2
OPTION–STEMI (2025)	66 (57–76)/ 65 (58–76)	80%/ 79%	49%/ 51%	59%/ 56%	42%/ 41%	8%/ 7%	60%/ 58%	50·3% ± 11/ 49.7% ± 11
MULTISTARS AMI (2023)	66 (58–74)/ 64 (55–73)	76.8%/ 80.8%	54.5%/ 50.2%	26.8%/ 27.1%	15.8%/ 15.4%	6.7%/ 4.8%	52.7%/ 48.9%	NR
BIOVASC (2023)	NR	NR	NR	NR	NR	NR	NR	NR
COCUA (2023)	63.3 ± 10.4/ 62.2 ± 10.9	79.6%/ 83%	54.3%/ 45.2%	36.8%/ 38.6%	40.7%/ 34.9%	0.9%/ 0.9%	52.4%/ 52.8%	50.5 ± 11.2/ 52.2 ± 10.9
Nichita-Brendea et al. (2021)	NR	74%/ 72%	40%/ 48%	NR	24%/ 22%	NR	50%/ 42%	42 (40–44)/ 45 (43–47)
Tarasov et al. (2017)	58.6 ± 10.2/ 59.1 ± 11.1	71.6%/ 62.3%	94%/ 88.4%	NR	23.9%/ 20.3%	14.9%/ 5.8%	NR	50.7 ± 9.2/ 51.8 ± 7.3
CvLPRIT (2015)	NR	NR	NR	NR	NR	NR	NR	NR
Maamoun et al. (2011)	54.52 ± 10.3/ 52.33 ± 7.1	95.2%/ 88.9%	38.1%/ 33.3%	57.1%/ 44.4%	40.5%/ 55.6%	NR	52.4%/ 55.6%	45.5 ± 8.8/ 45.0 ± 6.9
Politi et al. (2010)	64.5 ± 11.7/ 64.1 ± 11.1	76.9%/ 80%	49.2%/ 64.6%	NR	13.8%/ 18.5%	NR	NR	45.4 ± 10.4/ 45.9 ± 8.6
PRIMA (2004)	65 ± 8.3/ 67 ± 7.9	72.9%/ 75%	52.1%/ 47.7%	81.2%/ 90.9%	31.2%/ 34.1%	29.1%/ 22.7%	37.5%/ 43.1%	41.6 ± 4.3/ 41.9 ± 5
Cumulative	63.7/63.9	79.4%/79%	50.8%/51.3%	41.2%/41.9%	29.1%/29.7%	11.8%/12.3%	55.3%/55.0%	49.2%/48.7%

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