Acute coronary syndrome revascularization strategies with multi-vessel coronary artery disease

In acute coronary syndromes (ACS), revascularization is the standard of care. However, trials comparing contemporary coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are limited. Optimal revascularization in patients with multi-vessel coronary artery disease (MV-CAD) presenting with ACS is unclear. This is a multi-centred, retrospective observational study from a large, hospital system in the United States. We abstracted data on patients with MV-CAD and ACS from 2018 to 2022 who underwent revascularization with PCI, CABG or medically managed (MM). We evaluated multivariate statistics comparing categorical variables and outcomes, including all-cause mortality (ACM) and myocardial infarction (MI) at 1 year. All logistic and Cox proportional-hazard models were balanced using inverse probability treatment weights accounting for age and sex. There were 295 CABG patients [median age 66 (IQR 59.7, 73.1); 73% male], 1,559 PCI patients [median age 68.3 (IQR 60, 76.6); 69.1% male], and 307 MM patients [median age 70 (60.9, 77.1) 74% male]. Patients revascularized with PCI had higher ACM at 1 year [14.1% vs. 5.1%; HR 2.4, CI (1.5, 3.8), p<0.001] and similar mortality to MM (13.4%). CABG also demonstrated reduced 1 year MI rate compared to PCI (1.7% vs 3.9%; HR 0.36, CI 0.21, 0.61, p=<0.001), with similar 1 year rate of MI to MM (3.9%). In conclusion, CABG, compared to PCI and MM, is associated with lower mortality, and repeat ACS events at 1 year in patients with ACS and MV-CAD.