Timing of Complete Multivessel Revascularization in Patients Presenting with Non-ST-Elevation Acute Coronary Syndrome

BackgroundMultivessel coronary artery disease (MVD) is highly prevalent in patients presenting with non-ST-segment elevation myocardial infarction (NSTE-ACS) and is associated with worse clinical outcomes compared with single vessel disease patients. Complete revascularization of the culprit and all significant non-culprit lesions reduces the incidence of major adverse cardiac events, but the optimal timing of non-culprit artery revascularization remains unclear. MethodsThis prespecified substudy of the randomized BIOVASC trial included patients who presented with NSTE-ACS and MVD, defined as [≥] 1 non-culprit related coronary artery with a diameter of [≥] 2.5 mm and [≥] 70% stenosis as per visual estimation or positive coronary physiology testing. Risk differences of the composite of all-cause mortality, myocardial infarction, unplanned ischemia driven revascularization or cerebrovascular events and its individual components were compared between the patients who were randomized to immediate and staged complete revascularization at 30 days and 1 year. ResultsThe BIOVASC trial enrolled 1525 patients, 917 patients presented with NSTE-ACS, of whom 459 were allocated to the immediate complete and 458 to the staged complete revascularization group. The incidences of the primary composite outcome were similar in the two groups (7.9% vs. 10.1%, risk difference 2.2%, 95%CI -1.5 to 6.0, p = 0.24). Immediate complete revascularization was associated with a significant reduction in the incidence of myocardial infarction (2.0% vs. 5.3%, risk difference 3.3%, 95% confidence interval [CI] 0.9 to 5.7, p = 0.008), which was maintained after exclusion of procedure related myocardial infarctions occurring at the index or staged procedure (2.0% vs. 4.4%, risk difference 2.4%, 95%CI 0.1 to 4.7, p = 0.039). Unplanned ischemia driven revascularizations were also reduced in the immediate complete revascularization group (4.2% vs. 7.8%, risk difference 3.5%, 95%CI 0.4 to 6.6, p = 0.025). ConclusionsImmediate complete revascularization is safe in patients with NSTE-ACS and MVD and was associated with a reduction in myocardial infarctions and unplanned ischemia driven revascularizations at 1 year. Clinical PerspectiveWhat Is New? - This prespecified subanalysis of the BIOVASC trial shows that all spontaneous myocardial infarctions between the index and staged procedure occurred in the population of patients that initially presented with NSTE-ACS. At 30 days and 1 year patients randomized to immediate complete revascularization have fewer myocardial infarctions and unplanned ischemia driven revascularizations. What Are the Clinical Implications? - Immediate complete revascularization appears to be a safe strategy and can be a reasonable option for complete revascularization in patients presenting with NSTE-ACS and multivessel disease - In patients presenting with NSTE-ACS and multivessel disease, misjudgment of the culprit lesion or presence of multiple vulnerable plaques could have a role in the reduction of early occurring myocardial infarctions when performing an immediate complete strategy.