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Timing of Complete Multivessel Revascularization in NSTE-ACS Patients
Quick Takes
- The current analysis is a substudy from the BIOVASC trial of patients with NSTE-ACS and multivessel CAD undergoing immediate complete revascularization (ICR) vs. staged complete revascularization (SCR).
- Results showed no significant difference in the defined primary endpoint (all-cause mortality, MI, unplanned ischemia-driven revascularization, or cerebrovascular events) at 1 year when comparing ICR to SCR.
- When evaluating individual endpoints, patients randomized to ICR had fewer non–procedure-related MIs and unplanned ischemia-driven revascularizations.
Study Questions:
What are clinical outcomes among patients presenting with non–ST-segment elevation acute coronary syndrome (NSTE-ACS) and multivessel coronary artery disease (MVD) and undergoing immediate complete revascularization (ICR) compared to staged complete revascularization (SCR)?
Methods:
This prespecified substudy of the BIOVASC trial included patients with NSTE-ACS and MVD. Risk differences of the composite endpoint of all-cause mortality, myocardial infarction (MI), unplanned ischemia-driven revascularization (UIDR), or cerebrovascular events and its individual components were compared between ICR and SCR at 30 days and 1 year.
Results:
The BIOVASC trial enrolled 1,525 patients; 917 patients presented with NSTE-ACS, of whom 459 were allocated to ICR and 458 to SCR. Incidences of the primary outcome were similar in the two groups (7.9% vs. 10.1%, risk difference, 2.2%; 95% confidence interval [CI], -1.5 to 6.0; p = 0.15). ICR was associated with a significant reduction of MIs (2.0% vs. 5.3%, risk difference, 3.3%; 95% CI, 0.9 to 5.7; p = 0.006), which was maintained after exclusion of procedure-related MIs related to the index or staged procedure (2.0% vs. 4.4%, risk difference, 2.4%; 95% CI, 0.1 to 4.7; p = 0.039). UIDRs were also reduced in the ICR group (4.2% vs. 7.8%, risk difference, 3.5%; 95% CI, 0.4 to 6.6; p = 0.018).
Conclusions:
The authors conclude that ICR is safe in patients with NSTE-ACS and MVD and was associated with a reduction in MIs and UIDRs at 1 year.
Perspective:
The original BIOVASC trial (of a predominantly male cohort) compared ICR with SCR in patients presenting with the spectrum of ACS and MVD and showed that ICR was noninferior to SCR. All patients received Orsiro sirolimus-eluting stents. MVD was defined as ≥70% stenosis in a nonculprit vessel ≥2.5 mm in diameter by visual estimation or positive coronary physiology testing. The current substudy of NSTE-ACS patients from the BIOVASC trial showed no significant difference in the defined primary endpoint (all-cause mortality, MI, UIDR, or cerebrovascular events) when comparing ICR with SCR. When evaluating individual endpoints, patients randomized to ICR had fewer non–procedure-related MIs and UIDRs. The findings are limited by the fact that the original trial was not powered to answer the specific question of this analysis. Although there does not appear to be a signal for harm for ICR, the question about the need and timing of complete revascularization requires further study before being implemented in clinical practice.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Interventions and ACS
Keywords: Acute Coronary Syndrome, Myocardial Revascularization
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