New Insights on Treating Multivessel Coronary Artery Disease: Immediate vs. Staged Revascularization

Recent research presented at ESC Congress 2025 offers crucial insights into managing patients with multivessel coronary artery disease (CAD) who experience ST-segment elevation myocardial infarction (STEMI). The study highlights that performing complete revascularization during the initial procedure (immediate PCI) does not demonstrate noninferiority compared to a staged approach, where additional procedures are scheduled on a different day during the same hospital stay.

Multivessel disease, affecting nearly half of STEMI patients, involves blockage in more than one coronary artery. Current guidelines support complete revascularization, including treating the culprit lesion and other blocked vessels, to improve outcomes.

The OPTION-STEMI trial, conducted across 14 South Korean hospitals and involving 994 patients, compared two strategies: immediate complete revascularization during the initial PCI, and staged revascularization with additional PCI on another day during the same hospitalization. Results showed that at one-year follow-up, the combined endpoint of death, non-fatal myocardial infarction, and unplanned revascularization was slightly higher in the immediate group (13.1%) compared to the staged group (10.8%), but this difference was not statistically conclusive to prove noninferiority.

Subgroup analysis indicated that patients with signs of heart failure (Killip class ≥II) experienced more harm with immediate revascularization, suggesting caution in this subgroup. Conversely, patients without heart failure signs showed no significant difference between the approaches.

Secondary outcomes showed marginal differences, with non-fatal MI occurring slightly less in the immediate group, while mortality rates were similar. Overall, the findings suggest that staged revascularization may be safer for certain patient populations, especially those presenting with heart failure symptoms.

Professor Youngkeun Ahn emphasized that while recent trials had demonstrated noninferiority of immediate revascularization, this trial’s findings advise a more cautious, individualized approach, particularly in high-risk patients. The evidence indicates that limiting immediate complete revascularization to stable STEMI patients without signs of heart failure could optimize outcomes.

This study underscores the importance of personalized treatment strategies in managing complex CAD and highlights that a one-size-fits-all approach may not be appropriate. Ongoing research continues to refine best practices for improving patient prognosis in multivessel coronary artery disease.