Timing of Complete Multivessel Revascularization in Patients Presenting With Non-ST-Segment Elevation Acute Coronary
Jacob J Elscot1, Hala Kakar1, Paola Scarparo1
1Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands.
Insights
Immediate complete revascularization (ICR) in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and multivessel disease (MVD) is safe and reduces myocardial infarctions (MIs) and unplanned ischemia-driven revascularizations (UIDRs). Staged complete revascularization (SCR) showed similar overall outcomes but higher rates of MI and UIDR.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Complete revascularization in NSTE-ACS with MVD reduces adverse cardiac events.
- Optimal timing for complete revascularization in NSTE-ACS and MVD is not well-defined.
Purpose of the Study:
- To compare immediate complete revascularization (ICR) versus staged complete revascularization (SCR) in patients with NSTE-ACS and MVD.
- To evaluate the safety and efficacy of ICR versus SCR regarding major adverse cardiac events at one year.
Main Methods:
- A substudy of the BIOVASC trial involving patients with NSTE-ACS and MVD.
- Comparison of primary composite outcome (all-cause mortality, MI, UIDR, cerebrovascular events) and individual components between ICR and SCR groups at 1-year follow-up.
Main Results:
- No significant difference in the primary composite outcome between ICR and SCR (7.9% vs 10.1%, P=0.15).
- ICR significantly reduced myocardial infarctions (MIs) compared to SCR (2.0% vs 5.3%, P=0.006), including procedure-related MIs.
- ICR also led to a significant reduction in unplanned ischemia-driven revascularizations (UIDRs) (4.2% vs 7.8%, P=0.018).
Conclusions:
- Immediate complete revascularization (ICR) is a safe strategy for patients with NSTE-ACS and MVD.
- ICR demonstrated a significant reduction in MIs and UIDRs at one year compared to SCR.
Background:
Complete revascularization of the culprit and all significant nonculprit lesions in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and multivessel disease (MVD) reduces major adverse cardiac events, but optimal timing of revascularization remains unclear.
Objectives:
This study aims to compare immediate complete revascularization (ICR) and staged complete revascularization (SCR) in patients presenting with NSTE-ACS and MVD.
Methods:
This prespecified substudy of the BIOVASC (Percutaneous Complete Revascularization Strategies Using Sirolimus Eluting Biodegradable Polymer Coated Stents in Patients Presenting With Acute Coronary Syndrome and Multivessel Disease) trial included patients with NSTE-ACS and MVD. Risk differences of the primary composite outcome of all-cause mortality, myocardial infarction (MI), unplanned ischemia-driven revascularization (UIDR), or cerebrovascular events and its individual components were compared between ICR and SCR at 1 year.
Results:
The BIOVASC trial enrolled 1,525 patients; 917 patients presented with NSTE-ACS, of whom 459 were allocated to ICR and 458 to SCR. Incidences of the primary composite outcome were similar in the 2 groups (7.9% vs 10.1%; risk difference 2.2%; 95% CI: -1.5 to 6.0; P = 0.15). ICR was associated with a significant reduction of MIs (2.0% vs 5.3%; risk difference 3.3%; 95% CI: 0.9 to 5.7; P = 0.006), which was maintained after exclusion of procedure-related MIs occurring during the index or staged procedure (2.0% vs 4.4%; risk difference 2.4%; 95% CI: 0.1 to 4.7; P = 0.032). UIDRs were also reduced in the ICR group (4.2% vs 7.8%; risk difference 3.5%; 95% CI: 0.4 to 6.6; P = 0.018).
Conclusions:
ICR is safe in patients with NSTE-ACS and MVD and was associated with a reduction in MIs and UIDRs at 1 year.
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