Timing of Complete Revascularization with Multivessel PCI for Myocardial Infarction

Research output: Contribution to journalResearch articleContributedpeer-review


  • MULTISTARS AMI Investigators - (Author)
  • Department of internal Medicine with focus on Cardiology (at Herzzentrum Dresden)
  • Institute for Cardioanesthesia (at Herzzentrum Dresden)
  • Chair of Landscape Engineering
  • University Hospital Carl Gustav Carus Dresden
  • University Research Clinic
  • TUD Dresden University of Technology
  • Universitätsklinikum Schleswig-Holstein - Campus Lübeck
  • University Hospital Zurich
  • the Center for Translational and Experimental Cardiology
  • the Faculty of Medicine (B.E.S
  • M. Schindler
  • F.R.) and Center for Molecular Cardiology
  • University of Zurich
  • Inselspital University Hospital Bern
  • University of Bern
  • Cardiocentro Ticino Foundation
  • Ente Ospedaliero Cantonale
  • Lugano (M.M.) - all in Switzerland
  • Erasmus University Medical Center
  • Cardiology Unit
  • Rivoli Hospital
  • Turin (F.V.
  • G.Q.)
  • SS. Antonio e Biagio e Cesare Arrigo Hospital
  • Alessandria (M.V.)
  • Parma University Hospital
  • Parma (G.M.) - all in Italy
  • Helios Klinikum Pirna


BACKGROUND: In patients with ST-segment elevation myocardial infarction (STEMI) with multivessel coronary artery disease, the time at which complete revascularization of nonculprit lesions should be performed remains unknown.

METHODS: We performed an international, open-label, randomized, noninferiority trial at 37 sites in Europe. Patients in a hemodynamically stable condition who had STEMI and multivessel coronary artery disease were randomly assigned to undergo immediate multivessel percutaneous coronary intervention (PCI; immediate group) or PCI of the culprit lesion followed by staged multivessel PCI of nonculprit lesions within 19 to 45 days after the index procedure (staged group). The primary end point was a composite of death from any cause, nonfatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure at 1 year after randomization. The percentages of patients with a primary or secondary end-point event are provided as Kaplan-Meier estimates at 6 months and at 1 year.

RESULTS: We assigned 418 patients to undergo immediate multivessel PCI and 422 to undergo staged multivessel PCI. A primary end-point event occurred in 35 patients (8.5%) in the immediate group as compared with 68 patients (16.3%) in the staged group (risk ratio, 0.52; 95% confidence interval, 0.38 to 0.72; P<0.001 for noninferiority and P<0.001 for superiority). Nonfatal myocardial infarction and unplanned ischemia-driven revascularization occurred in 8 patients (2.0%) and 17 patients (4.1%), respectively, in the immediate group and in 22 patients (5.3%) and 39 patients (9.3%), respectively, in the staged group. The risk of death from any cause, the risk of stroke, and the risk of hospitalization for heart failure appeared to be similar in the two groups. A total of 104 patients in the immediate group and 145 patients in the staged group had a serious adverse event.

CONCLUSIONS: Among patients in hemodynamically stable condition with STEMI and multivessel coronary artery disease, immediate multivessel PCI was noninferior to staged multivessel PCI with respect to the risk of death from any cause, nonfatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure at 1 year. (Supported by Boston Scientific; MULTISTARS AMI ClinicalTrials.gov number, NCT03135275.).


Original languageEnglish
Pages (from-to)1368-1379
Number of pages12
JournalThe New England journal of medicine
Issue number15
Publication statusPublished - 12 Oct 2023

External IDs

Scopus 85171138244



  • Humans, Coronary Artery Disease/complications, Heart Failure/etiology, Myocardial Infarction/etiology, Myocardial Revascularization/adverse effects, Percutaneous Coronary Intervention/adverse effects, ST Elevation Myocardial Infarction/etiology, Stroke/etiology, Treatment Outcome, Time Factors, Europe, Coronary Vessels/surgery