Revascularisation in acute coronary syndromes: change in practice?

Currently, we are in an era of fine-tuning the acute and long-term treatment of acute coronary syndromes, with specific attention to certain groups at high risk, such as people with multivessel coronary disease. More than half of the patients presenting with an acute coronary syndrome have multivessel coronary disease, 1 Sorajja P Gersh BJ Cox DA et al. Impact of multivessel disease on reperfusion success and clinical outcomes in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction. Eur Heart. 2007; 28: 1709-1716 Crossref PubMed Scopus (361) Google Scholar and with an ageing population and increasing incidence of comorbidities, such as hypertension, diabetes, inactivity, and obesity, this subset of patients will only continue to grow. Over the past decade, the clinical approach has shifted from culprit-only to complete revascularisation of all coronary lesions supported by both the European and American guidelines. 2 Wald DS Morris JK Wald NJ et al. Randomized trial of preventive angioplasty in myocardial infarction. N Engl J Med. 2013; 369: 1115-1123 Crossref PubMed Scopus (773) Google Scholar , 3 Gershlick AH Khan JN Kelly DJ et al. Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel disease: the CvLPRIT trial. J Am Coll Cardiol. 2015; 65: 963-972 Crossref PubMed Scopus (565) Google Scholar , 4 Engstrøm T Kelbæk H Helqvist S et al. Complete revascularisation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multivessel disease (DANAMI-3–PRIMULTI): an open-label, randomised controlled trial. Lancet. 2015; 386: 665-671 Summary Full Text Full Text PDF PubMed Scopus (634) Google Scholar , 5 Smits PC Abdel-Wahab M Neumann FJ et al. Fractional flow reserve-guided multivessel angioplasty in myocardial infarction. N Engl J Med. 2017; 376: 1234-1244 Crossref PubMed Scopus (468) Google Scholar , 6 Mehta SR Wood DA Storey RF et al. Complete revascularization with multivessel PCI for myocardial infarction. N Engl J Med. 2019; 381: 1411-1421 Crossref PubMed Scopus (398) Google Scholar , 7 Ibanez B James S Agewall S et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2018; 39: 119-177 Crossref PubMed Scopus (5768) Google Scholar , 8 Collet JP Thiele H Barbato E et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021; 42: 1289-1367 Crossref PubMed Scopus (1963) Google Scholar However, data considering the optimal timing of this complete—ie, immediate versus staged—revascularisation is scarce or conflicting. 9 Sardella G Lucisano L Garbo R et al. Single-staged compared with multi-staged PCI in MULTIVessel NSTEMI patients: the SMILE trial. J Am Coll Cardiol. 2016; 67: 264-272 Crossref PubMed Scopus (79) Google Scholar This is an important issue, not only for the individual patient, but also for health-care systems because the increased pressure on health-care systems and rising health-care costs worldwide highlight the need for optimal clinical pathways in times of increasingly constrained resources. These pathways should be supported by clinical data demonstrating their safety and effectiveness. Immediate versus staged complete revascularisation in patients presenting with acute coronary syndrome and multivessel coronary disease (BIOVASC): a prospective, open-label, non-inferiority, randomised trialIn patients presenting with acute coronary syndrome and multivessel disease, immediate complete revascularisation was non-inferior to staged complete revascularisation for the primary composite outcome and was associated with a reduction in myocardial infarction and unplanned ischaemia-driven revascularisation. Full-Text PDF