Now Or Later? Immediate Versus Staged Complete Revascularization In Patients Presenting With Acute Coronary Syndrome And Multivessel Coronary Disease

At the 2023 American College of Cardiology Scientific Sessions, Roberto Diletti and colleagues presented the BIOVASC (Immediate versus staged complete revascularization and patients presenting with acute coronary syndrome and multivessel coronary disease) study to investigate the ideal timing of revascularization on non-culprit lesions when a patient presents with acute coronary syndrome with multi-vessel disease. The study illustrated non-inferiority of immediate complete revascularization compared to staged complete revascularization.¹

This study was an open-label, prospective randomized trial involving 29 hospitals across Belgium, Spain, Italy and the Netherlands. Included patients were 18-85 years old presenting with ST-segment elevation myocardial infarction or non-ST-segment elevation acute coronary syndrome who were found to have multivessel coronary artery disease with a clearly identifiable culprit lesion. Multivessel disease was defined as having two or more coronary arteries with a diameter of at least 2.5mm with stenoses ≥ 70% per angiography or hemodynamic significance based on invasive physiologic testing. The primary outcome was the composite of all-cause mortality, myocardial infarction (MI), or any unplanned revascularization resulting from ischemia.

A total of 764 patients were included in the immediate revascularization group compared to 761 in the staged group. At 1 year, the incidence of the primary outcome was 7.6% in the immediate revascularization group compared to 9.4% in the staged procedure group. While there was no difference in all-cause mortality, the immediate revascularization group had lower rates of MI  (HR 0·41, 95% CI 0·22–0·76, p=0·0045) and unplanned ischemia-driven revascularization group (HR 0·61, 95% CI 0·39–0·95, p=0·030).

The introduction of percutaneous coronary intervention has revolutionized the management of acute coronary syndrome. Many of these patients have multivessel coronary artery disease which has been shown to have worse outcomes compared to those patients that present with acute coronary syndrome with single-vessel disease.^2,3 The added wrinkle of multivessel coronary artery disease continues to challenge operators for the best approach to revascularization. In 2021 the COMPLETE trial highlighted that in STEMI patients that revascularization of all lesions was superior to revascularization of the culprit only lesion. In the COMPLETE trial, revascularization was done both during the index procedure or as a staged PCI. While this study was paramount to the model of approach to multivessel CAD, it did not answer the question of timing. The BIOVASC study is the first to look at this important question.

Dr. Usman Hasnie is a cardiology fellow at the University of Alabama at Birmingham and served as a CardioNerds Conference Scholar for the American College of Cardiology 2023 Scientific Sessions.

 References

1. Diletti R, den Dekker WK, Bennett J, et al., on behalf of the BIOVASC Investigators. Immediate versus staged complete revascularization in patients presenting with acute coronary syndrome and multivessel coronary disease (BIOVASC): a prospective, open-label, non-inferiority, randomized trial. Lancet 2023;Mar 5:[Epub ahead of print].
2. Goldstein JA, Demetriou D, Grines CL, Pica M, Shoukfeh M,O’Neill WW. Multiple complex coronary plaques in patients withacute myocardial infarction. N Engl J Med 2000; 343: 915–22
3. Sorajja P, Gersh BJ, Cox DA, et al. Impact of multivessel disease onreperfusion success and clinical outcomes in patients undergoingprimary percutaneous coronary intervention for acute myocardial Eur Heart J 2007; 28: 1709–16.