Revascularization Strategies for Multivessel Disease in Acute Coronary Syndrome: Network Meta-analysis

The optimal revascularization strategy for patients with acute coronary syndrome (ACS) and multivessel disease (MVD) remains debated. This study compares the efficacy and safety of different revascularization strategies in these patients.

We included 20 studies comparing staged, complete, and culprit-only (CO) revascularization strategies in patients with ACS and MVD. We divided the revascularization strategies into 3 distinct strategies: CO, complete index procedure (CIP), and complete staged procedure (CSP). We then compared CIP and CSP with CO. Outcomes studied are all-cause mortality, cardiac death, recurrent myocardial infarction (MI), need for revascularization, bleeding, contrast-induced nephropathy (CIN), stroke, bleeding, and stent thrombosis.

Compared with the CO group, both the CIP group (relative risk [RR], 0.42; 95% CI, 0.26-0.69; P < .001) and the CSP group (RR, 0.53; 95% CI, 0.35-0.82; P < .001) showed a lower need for revascularization. The CSP group had a lower incidence of cardiac death (RR, 0.67; 95% CI, 0.48-0.94; P = .02). The CIP group experienced fewer recurrent MI (RR, 0.58; 95% CI, 0.35-0.94; P = .03). There was no statistically significant difference in all-cause mortality, bleeding, CIN, stroke, or stent thrombosis between the CIP group and the CSP group compared with the CO group.

Our findings support complete revascularization (CIP or CSP) over CO for patients with ACS and MVD. Both CIP and CSP are associated with lower needs for future revascularization. CSP was associated with lower cardiac deaths. CIP was associated with fewer recurrent MI. Additionally, both strategies were safe with no differences noted in bleeding, CIN, stroke, and stent thrombosis.