Timing of Complete Revascularization Stratified by Index Presentation During On- and Off-Hours

Area of Science:

• Cardiology
• Interventional Cardiology
• Clinical Trials

Background:

• Recent trials indicate immediate complete revascularization (ICR) is a safe alternative to staged complete revascularization (SCR).
• The comparative effectiveness of ICR versus SCR during on-hours versus off-hours in acute coronary syndromes (ACS) remains unclear.
• On-hours procedures were defined as those occurring between 8:00 a.m. and 6:00 p.m., Monday to Friday.

Purpose of the Study:

• To evaluate the impact of percutaneous coronary intervention (PCI) timing (on-hours vs. off-hours) on the outcomes of ICR versus SCR strategies.
• To assess potential differential treatment effects between ICR and SCR based on procedural timing in patients with ACS and multivessel disease.

Main Methods:

• Analysis of data from the BIOVASC trial, which enrolled 1,097 patients during on-hours and 428 during off-hours.
• Utilized Cox regression models to analyze the primary composite outcome (all-cause mortality, myocardial infarction, unplanned ischemia-driven revascularization, cerebrovascular events) at 1-year follow-up.
• Evaluated multiplicative and additive interactions between procedural timing (on- vs. off-hours) and randomized treatment allocation (ICR vs. SCR).

Main Results:

• Patients randomized during off-hours presented more frequently with ST-segment elevation myocardial infarction (STEMI).
• The primary composite outcome occurred in 8.4% of ICR and 10.1% of SCR patients during on-hours (HR 0.80; 95% CI 0.54-1.19).
• During off-hours, the primary composite outcome occurred in 5.4% of ICR and 7.7% of SCR patients (HR 0.69; 95% CI 0.32-1.46), with no statistically significant interaction (p=0.70 multiplicative, p=0.56 additive).

Conclusions:

• No differential treatment effect was observed when comparing immediate complete revascularization (ICR) versus staged complete revascularization (SCR) in patients with acute coronary syndrome and multivessel disease, irrespective of whether procedures were performed during on- or off-hours.
• The safety and efficacy of ICR versus SCR appear consistent across different procedural time windows.
• These findings support the established guidelines for complete revascularization strategies in ACS patients regardless of the timing of intervention.