Initial Complete Revascularization vs. Staged Revascularization in Patients with STEMI and Multivessel Disease

In patients with ST-segment elevation acute myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (primary PCI), multivessel disease is observed in up to 40% of cases. The optimal timing for revascularizing non-culprit lesions in these patients without cardiogenic shock remains a controversial issue. European guidelines recommend completing revascularization during the initial procedure or within 45 days in patients with STEMI and multivessel disease without cardiogenic shock (Class I Recommendation, Level of Evidence A).

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The BioVasc Study demonstrated the non-inferiority of initial complete revascularization compared with staged complete revascularization in patients with acute coronary syndrome (ACS), whether with or without ST-segment elevation. Additionally, initial complete revascularization was associated with a reduction in the number of events of myocardial infarction and unplanned ischemia-driven revascularization.

The aim of this sub-analysis of the BioVasc Study—a multicenter, prospective, randomized non-inferiority trial—was to assess the clinical outcomes of initial complete revascularization (ICR) versus staged complete revascularization (SCR) in patients with STEMI.

The primary endpoint (PE) was a composite of all-cause death, acute myocardial infarction, unplanned ischemia-driven revascularization, or cerebrovascular events at 1 year from the index procedure. The secondary endpoint (SE) included the PE at 30 days, the individual components of the PE at 30 days and 1 year, stent thrombosis, target vessel revascularization, and major bleeding at 30 days and 1 year.

The sub-analysis included a total of 608 patients; 305 were assigned to the ICR group and 303 to the SCR group. The mean age was 63 years, and most patients were men. The culprit lesion was most frequently located in the right coronary artery, followed by the left anterior descending artery. Intravascular imaging was used in 7.5% of cases in the ICR group versus 13.9% in the SCR group (p=0.012). Functional assessment of non-culprit lesions by means of FFR/IFR was performed in 13.4% of cases in the ICR group and 18.2% in the SCR group (p=0.11). The amount of contrast used was higher in the SCR group (p<0.001). The duration of hospital stay was shorter in the ICR group (3 days) compared with the SCR group (4 days) (p<0.001).

Regarding outcomes, the PE occurred in 7% of patients in the ICR group and 8.3% of patients in the SCR group (hazard ratio [HR] 0.84, 95% confidence interval [CI]: 0.47-1.50; p=0.55). There were no statistically significant differences in the individual analysis of the PE components. At 30 days of follow-up, there was a trend towards a reduction in the PE in the ICR group (ICR 3.0% vs SCR 6.0%, HR 0.50, 95% CI: 0.22-1.11; p=0.09).

Conclusion

This sub-analysis showed that, in patients with STEMI and multivessel disease, both initial complete revascularization and staged complete revascularization had similar clinical outcomes at 1 year of follow-up.