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Optimal revascularization strategy in patients with acute coronary syndrome and multivessel disease: insights from a

Andrea Milzi1,2, Stefano Benenati3, Antonio Landi4,5

  • 1Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), Via Tesserete 48, CH-6900, Lugano, Switzerland. andrea.milzi@eoc.ch.

Clinical Research in Cardiology : Official Journal of the German Cardiac Society
|June 30, 2025
PubMed

Insights

For acute coronary syndrome (ACS) patients with multivessel disease (MVD), complete revascularization guided by either angiography or physiology significantly reduces major adverse cardiac events compared to culprit-only treatment. Physiology-guided revascularization shows the greatest benefit for reducing mortality.

Area of Science:

  • Cardiology
  • Interventional Cardiology
  • Clinical Trials

Background:

  • Coronary multivessel disease (MVD) is present in about 50% of acute coronary syndrome (ACS) patients.
  • The optimal strategy for revascularizing non-culprit lesions in ACS with MVD remains unclear.
  • Current approaches include culprit-only revascularization, angiography-guided complete revascularization, and physiology-guided complete revascularization.

Purpose of the Study:

  • To compare the effectiveness of culprit-only, angiography-guided complete, and physiology-guided complete revascularization strategies.
  • To evaluate outcomes in patients with ACS and MVD undergoing different revascularization approaches.

Main Methods:

  • A systematic search of randomized controlled trials was conducted in PubMed and Web of Science.
  • Included studies focused on ACS patients with MVD comparing the three revascularization strategies.
  • Data from 14 trials involving 11,871 participants were analyzed.

Main Results:

  • Complete revascularization, both angiography- and physiology-guided, significantly reduced major adverse cardiac events (MACE) compared to culprit-only intervention.
  • Angiography-guided complete revascularization showed a lower MACE rate (IRR 0.60) and physiology-guided complete revascularization showed a similar rate (IRR 0.65).
  • Physiology-guided revascularization demonstrated the highest estimated benefit for reducing all-cause and cardiovascular death.

Conclusions:

  • Both angiography-guided and physiology-guided complete revascularization are superior to culprit-only revascularization in reducing MACE for ACS patients with MVD.
  • Physiology-guided complete revascularization appears to offer the greatest survival benefit.
  • Further research may refine optimal selection criteria for non-culprit lesion revascularization.

Keywords:
Acute coronary syndromeComplete revascularizationCoronary artery diseaseCoronary physiologyPercutaneous coronary intervention

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