Timing in Complete Revascularization in Acute Coronary Syndrome: BIOVASC 2-Year Followup

The concept of complete revascularization (CR) has been comprehensively studied, leading to diverse approaches and debates on optimal timing. 

The BIOVASC trial explored the ideal timing for CR in patients with acute coronary syndrome (ACS) and multivessel disease. This multicenter study carried out in four European countries showed that immediate CR is no inferior to the staged strategy as regards the combined outcome of all-cause mortality, acute MI, unplanned revascularization or cerebrovascular events. 

Another study called MULTISTARS also confirmed non-inferiority for immediate CR vs the staged strategy in patients with ST elevation MI. Subsequent meta-analysis including these studies showed no significant differences in major adverse cardiovascular events (MACE), with a lower incidence of ACS with the immediate strategy. 

Complete Revascularization in Acute Coronary Syndrome

The aim of this analysis was to report BIOVASC two-year outcomes. Multivessel disease was defined as the presence of two or more arteries with ≥2.5 mm diameter and ≥70% stenosis. In staged patients, CR was done during initial hospitalization or within the following six weeks. It excluded patients with prior revascularization with coronary artery bypass graft (CABG), or chronic total occlusions (CTO), or cardiogenic shock. 

Read also: Coronary Sinus Reducer for Refractory Angina: Notes from the REDUCER-I Study.

The main validation criterion was the combined outcome previously described for BIOVASC. It included 1,525 patients and 97.6% completed the 2 year followup or presented an event. 62.5% of culprit lesions were classified as type B2 or C according to ACC-AHA. Mean SYNTAX score at baseline was 14, and ≤8 residual SYNTAX score was reached by 92.7% of immediate strategy patients and 90.3% of the staged patients (P = 0.086).

At 2 years, there were no significant differences in the combined outcome (HR: 0.98; CI 95%: 0.73-1.30; P = 0.88). Its individual components also showed no differences in all-cause mortality (HR: 1.67; CI 95%: 0.88-3.16; P = 0.12) or unplanned revascularization (HR: 0.87; CI 95%: 0.60-1.26; P = 0.45). However, there was a lower incidence of AMI among immediate strategy patients (3.8% vs. 6.2%; HR: 0.60; CI 95%: 0.37-0.96; P = 0.032).

Both prespecified subgroup and landmark analysis showed the absence of significant differences between the assessed strategies. 

Conclusions: Immediate vs Staged Revascularization Strategies in ACS

The two-year followup of BIOVASC reaffirms the original results, showing no significant differences between immediate and staged revascularization in ACS patients. Likewise, there was lower incidence of AMI among CR patients. 

Original Title: Timing of Complete Multivessel Revascularization in Acute Coronary Syndrome: 2-Year Results of the BIOVASC Study.

Reference: den Dekker WK, Elscot JJ, Bennett J, Schotborgh CE, van der Schaaf R, Sabaté M, Moreno R, Ameloot K, van Bommel R, Forlani D, van Reet B, Esposito G, Dirksen MT, Ruifrok WPT, Everaert BRC, Van Mieghem C, Cummins P, Lenzen M, Brugaletta S, Boersma E, Van Mieghem NM, Diletti R; BIOVASC Investigators. Timing of Complete Multivessel Revascularization in Acute Coronary Syndrome: 2-Year Results of the BIOVASC Study. JACC Cardiovasc Interv. 2024 Dec 23;17(24):2866-2874. doi: 10.1016/j.jcin.2024.09.058. PMID: 39722269.