BACKGROUND: Randomized controlled trials (RCTs) of complete revascularization (CR) versus culprit-only revascularization (COR) in patients with ST-elevation myocardial infarction (STEMI) have shifted the recommendation for CR from class III to class I in the AHA/ACC/SCAI guidelines, but it remains unclear if the benefit of CR over COR extends to older adults, who have greater bleeding risk, comorbidity burden, and complexity of lesions. We performed a meta-analysis to place the results of the previous RCTs in the context of the recently published FIRE trial and the subgroup analysis of the COMPLETE trial in adults ≥75 years old. METHODS: We searched the literature from inception to October 21, 2023. RCTs of CR versus COR in STEMI were selected if it reported results for older adults, defined as either age >
65 years or >
75 years. Integrated hazard ratios (HRs) were calculated using random effects models. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes were major bleeding and contrast-associated acute kidney injury (CA-AKI). RESULTS: In this meta-analysis of 5 RCTs including 3513 older adults, CR was associated with a lower hazard of MACE than COR (HR 0.60, 95% CI 0.37-0.99, p = 0.047). Sensitivity analysis including trials that defined older adults as age >
65 years resulted in a lower hazard of MACE with CR versus COR, but not in trials that defined older adults as age >
75 years. There was no difference in the hazard of major bleeding or CA-AKI between CR and COR. CONCLUSIONS: In this largest meta-analysis to date investigating CR compared with COR in older adults with STEMI, CR was associated with reduced MACE without a concomitant increase in major bleeding or CA-AKI compared with COR. These results can help cardiologists and geriatricians involved in shared decision-making with patients and caregivers when contemplating whether to pursue CR in older adults.