The MULTISTARS AMI (MULTivessel Immediate versus STAged RevaScularization in Acute Myocardial Infarction) trial compared immediate versus delayed percutaneous coronary intervention (PCI) of nonculprit lesions in patients with ST-segment elevation myocardial infarction (STEMI) who underwent successful primary PCI of the culprit lesion.¹ Eligible patients included those with a hemodynamically stable STEMI identified within 24 hours of symptom onset and found to have multivessel coronary artery disease (CAD) with at least one additional lesion suitable for PCI (≥70% stenosis by angiography). A total of 840 patients were randomized (1:1 open-label study) to either undergo immediate PCI (n = 418) of the nonculprit lesion or staged intervention within 19-45 days after PCI of the culprit vessel. Patients already planned for non-culprit-lesion revascularization or surgical revascularization and those with previous coronary artery bypass grafting or logistical barriers to participation were excluded. The primary endpoint was a composite of all-cause mortality, nonfatal myocardial infarction (MI), stroke, unplanned ischemia-driven target-lesion revascularization (ID-TLR), or heart failure hospitalization.

At 1 year, the primary endpoint occurred in 8.5% of patients in the immediate-intervention group versus 16.3% of patients in the delayed-intervention group (p < 0.001). The immediate-intervention group had lower rates of nonfatal MI (2% vs. 5.3%; p < 0.05) and ID-TLR (4.1% vs. 9.3%; p < 0.05). All-cause mortality rates were similar (2.9% vs. 2.6%) between the groups.

These findings suggest that immediate PCI for nonculprit multivessel CAD in patients presenting with stable STEMI is noninferior to staged PCI; in fact, immediate intervention was statistically superior based on the primary endpoint. Limitations of this study included low representation of women and limited use of intravascular coronary imaging. There was also possible ascertainment bias, which may have favored the immediate-intervention group regarding lower rates of periprocedural MI given the difficulty in diagnosis.

This trial's findings build on those of the COMPLETE (Complete Versus Culprit-Only Revascularization Strategies to Treat Multivessel Disease After Early PCI for STEMI) trial, which showed the benefit of complete revascularization in patients who underwent staged nonculprit PCI,² as this trial's findings demonstrated the safety (and noninferiority) of intervention during the index catheterization. These findings are similar to those of the BIOVASC (Percutaneous Complete Revascularization Strategies Using Sirolimus-Eluting Biodegradable Polymer-Coated Stents in Patients Presenting With Acute Coronary Syndrome and Multivessel Disease) trial, although that trial also included patients with non-STEMI and unstable angina.³ Future studies would benefit from broader recruitment and investigation of staged intervention performed within a shorter interval (perhaps during the initial hospitalization).

References

1. Stähli BE, Varbella F, Linke A, et al.; MULTISTARS AMI Investigators. Timing of complete revascularization with multivessel PCI for myocardial infarction. N Engl J Med 2023;389:1368-79.
2. Mehta SR, Wood DA, Storey RF, et al.; COMPLETE Trial Steering Committee and Investigators. Complete revascularization with multivessel PCI for myocardial infarction. N Engl J Med 2019;381:1411-21.
3. Diletti R, den Dekker WK, Bennett J, et al. Immediate versus staged complete revascularisation in patients presenting with acute coronary syndrome and multivessel coronary disease (BIOVASC): a prospective, open-label, non-inferiority, randomised trial. Lancet 2023;401:117282.