Revascularization Timing in Acute Coronary Syndrome

Multivessel disease is often present in ST elevation acute myocardial infarction (STEMI) patients. The AHA/ACC 2021 revascularization guidelines recommend staged complete revascularization as class I, single-setting complete revascularization as class 2b, and recommend against culprit only revascularization.

Nueva y discrepante información sobre los vasos no culpables en el infarto

At present, we have more randomized studies (BIOVASC, FIRE and MULTISTAR) comparing staged vs single-setting complete revascularization, but we lack information to decide on the best strategy.

This was a meta-analysis of 16 randomized studies including 11,876 STEMI and NSTEMI patients undergoing culprit only, single-setting, and staged complete revascularization, excluding those with cardiogenic shock.

Primary end point was cardiovascular death or AMI.

3,056 patients received single-setting complete revascularization (25.7%), 4,328 patients received staged complete revascularization (36.4%) and 4,492 patients received culprit-only revascularization (37.8%). Mean age was 65 and they were mostly men.

Primary end point resulted in favor of single-setting complete revascularization (odds ratio [OR], 0.52 [95% CI, 0.41–0.65]; OR, 0.74 [95% CI, 0.62–0.88] for staged complete and culprit only revascularization respectively), making this one the strategy of choice, followed by complete staged and finally culprit only.

Reduction in adverse events rate (MACE) also favored single-setting complete revascularization over the other two (OR, 0.42 [95% CI, 0.32–0.56]; OR, 0.62 [95% CI, 0.47–0.82] for complete staged and culprit only respectively), also all-cause mortality and AMI (OR, 0.52 [95% CI, 0.40–0.67]; OR, 0.78 [95% CI, 0.67–0.91]), AMI (OR, 0.39 [95% CI, 0.26–0.57]; OR, 0.73 [95% CI, 0.59–0.90]) and need for unplanned revascularization (OR, 0.30 [95% CI, 0.18–0.47]; OR, 0.46 [95% CI, 0.30–0.71]).

There were no differences in cardiovascular mortality between the strategies.

These results were consistent across STEMI, NSTEMI and unstable angina patients.

Conclusion

Single-setting complete revascularization might offer greater reduction of cardiovascular events rate in patients with acute myocardial infarction and multivessel disease. We need more, large scale, randomized studies comparing single-setting vs staged complete revascularization procedures to better assess the optimal timing for complete revascularization.