Acute Coronary Syndrome with Multivessel Disease: Best Revascularization Strategy

The gold standard treatment for acute coronary syndrome (ACS), especially acute myocardial infarction (AMI) is primary angioplasty (PCI). However, 40 to 70% of ACS patients present multivessel disease, which presents a therapeutic challenge. 

Several analyses have shown complete revascularization is the preferred strategy to treat these cases. However, its optimal timing remains controversial: should it be one single procedure or a staged procedure? How long apart should interventions be? 

A meta-analysis of 20 randomized studies was carried out, including 13,823 ACS patients treated with percutaneous coronary intervention (PCI) comparing three strategies: culprit only revascularization (CO), complete revascularization at the time of index procedure (CIP) and staged procedure (SIP).

Mean patient age was 62.6, 77% were men, 53% hypertensive, 34% diabetic, 9.6% had suffered prior MI and 8.3% had cardiac failure. 

Cardiac mortality was lower with CIP vs. CO (RR: 0.67; CI 95%: 0.48-0.94; p = 0.022). However, there were no significant differences between CO and CIP (RR: 0.74; CI 95%: 0.49-1.11; p = 0.14). Neither were there differences in all-cause mortality between the 3 strategies.

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The need for revascularization was lower in CIP and CSP vs CO (RR, 0.42; CI, 0.26-0.69; P < .01 y RR, 0.53; CI, 0.35-0.82; P <.01 respectively).

The need for future revascularization was lower with CIP and CSP vs CO (CIP: RR: 0.42; CI 95%: 0.26-0.69; p < 0.01; CSP: RR: 0.53; CI 95%: 0.35-0.82; p < 0.01).

Recurrent MI was lower win CIP vs CO (RR, 0.58; CI, 0.35-0.94; P = .027) but there was no significant difference between CSP and CO (RR = 0.98; CI, 0.66-1.48; P = .94)

CIP showed lower risk of repeat MI vs CO (RR: 0.58; IC 95%: 0.35-0.94; p = 0.027). There were no significant differences between CSP and CO (RR: 0.98; IC 95%: 0.66-1.48; p = 0.94).

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No differences were found as regards bleeding, kidney function deterioration, stroke or stent thrombosis, between the strategies. 

Conclusion 

These findings support complete revascularization (either CIP or CSP) as better compared against culprit only revascularization (CO) in patients with acute coronary syndrome and multivessel disease. Both strategies reduced the need for future revascularization. CSP was associated with lower cardiac mortality, while CIP showed lower risk of recurrent MI. Also, both options resulted safe, with no differences in adverse events such as bleeding, kidney function deterioration or stent thrombosis.  

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

Reference: Khaled M. Harmouch,  et al. Journal of the Society for Cardiovascular Angiography & Interventions 4 (2025) 102449 https://doi.org/10.1016/j.jscai.2024.102449.