Percutaneous coronary revascularisation in multivessel disease associated with NSTE-ACS: what is the ideal strategy?

Abstract Introduction Multivessel disease (MVD) affects 50% of patients with an acute coronary syndrome (ACS) and is associated with poor clinical outcomes and high mortality. There is limited evidence regarding the option of complete revascularisation (CR) in cases of MVD and non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Purpose The purpose is to determine the impact of the type of percutaneous coronary revascularisation on the prevalence of major adverse cardiovascular and cerebrovascular events (MACCE) in patients with MVD and NSTE-ACS. Methods Observational, longitudinal, analytical, ambispective cohort. Patients with NSTE-ACS non-ST-segment elevation myocardial infarction (NSTEMI) or unstable angina (UA) and MVD who underwent a revascularisation strategy via percutaneous coronary intervention (PCI) were included, either during the index procedure (IP) or in staged procedures, during the index hospitalisation or deferred periods ≤ 12 months from the first intervention, with a minimum clinical follow-up of one year. Two groups were assigned: the first included patients undergoing CR, either during the IP or in staged procedures, while the second included patients undergoing culprit-only revascularisation (COR). The primary endpoint was the incidence of MACCE, defined as all-cause mortality, cardiac death, reinfarction, repeat coronary revascularisation, rehospitalisation for UA, and stroke at one year. MACCE survival was assessed using Kaplan-Meier curves, and statistical differences between groups were evaluated with the log-rank test. A p-value 0.05 was considered statistically significant. Results From April 2020 to August 2023, 146 patients were included, NSTEMI (n = 49) and UA (n = 97), of whom 76.7% (n = 112) underwent a CR strategy, while 23.3% (n = 34) received COR. Within the CR group, 67.9% (n = 76) achieved CR during the IP, and 32.1% (n = 36) in staged procedures. According to Kaplan-Meier curves, at one-year, CR showed a lower number of MACCE, with 10.7% in CR (n = 12) and 44.1% in COR (n = 15), (HR 0.286 95% CI, 0.093–0.878; log-rank p = 0.0024) (Figure 1-A, Table 1). In the subgroup comparison of both revascularisation strategies (CR and COR), during IP and staged procedures, fewer MACCE were observed in CR performed during the IP (log-rank p = 0.0143) (Figure 1-B). When analysing individual events, CR showed a lower risk of repeat coronary revascularisation (log-rank p = 0.0259). In the evaluation of subgroups undergoing CR, the incidence of MACCE was 7.9% in IP group (n = 6) and 16.7% in staged procedures (n = 6), (HR 0.462 95% CI, 0.137–1.561; log-rank p = 0.1706). Conclusions Complete percutaneous coronary revascularisation in patients with NSTE-ACS associated with MVD showed a lower number of MACCE at one-year follow-up compared to COR. The findings support the implementation of a CR strategy, which is associated with greater benefit when performed during the IP, provided this is feasible.MACCE MACCE in revascularisation strategies