Immediate versus staged revascularization in acute coronary syndrome and multivessel disease: a meta-analysis and meta-regression of RCTs

In patients presenting with acute coronary syndrome (ACS) and multivessel disease, it is unclear whether non-culprit lesions should be revascularized immediately or in a staged procedure. We performed a meta-analysis of randomized controlled trials that compared immediate versus staged revascularization strategies. Two authors independently screened records from the online databases PubMed, Embase, Web of Science, and the Cochrane Library to identify eligible trials up to November 2025. The primary outcome was all-cause mortality at 1 year. Secondary outcomes included cardiovascular events at 1 year. Meta-regressions were performed to explore the influence of study-level characteristics. This study was registered in PROSPERO (CRD42023446181). Ten trials with a total of 5651 patients were included in the final analysis. All-cause death at 1 year occurred in 109 (3.9%) of 2809 patients in the immediate revascularization group and 100 (3.5%) of 2842 patients in the staged revascularization group (risk ratio, 1.10; 95% CI 0.79-1.52). Cardiovascular death at 1 year occurred in 76 (2.8%) of 2749 patients in the immediate revascularization group and 66 (2.4%) of 2768 patients in the staged revascularization group. Meta-regression suggested that higher mean patient age was significantly associated with a lower risk ratio favoring the immediate revascularization group (regression coefficient -0.10; 95% CI -0.16 to -0.002; p = 0.047). All-cause mortality and cardiovascular deaths were similar in patients with ACS, predominantly with STEMI, and multivessel coronary disease undergoing immediate or staged revascularization. The available effect estimates do not exclude the possibility of clinically meaningful benefit or harm from immediate revascularization.