Immediate revascularization reduces myocardial infarction rates compared to staged revascularization in multivessel coronary disease

1. The immediate revascularization group met the noninferiority criteria for the primary composite outcome, but superiority at the 1-year follow-up was not met.

2. A marked reduction in myocardial infarction was noted in the immediate revascularization group compared to the staged revascularization group.

Evidence Rating Level: 1 (Excellent)

Study Rundown: In patients with acute coronary syndrome due to multivessel disease, guidelines suggest that complete revascularization yields a greater benefit as opposed to exclusive reperfusion of the infarct-related artery. However, the appropriate timing to treat non-culprit lesions remains unclear. This randomized controlled trial aimed to compare clinical outcomes in patients who underwent immediate revascularization and staged revascularization for multivessel acute coronary syndrome. The primary outcome was a composite of all-cause mortality, myocardial infarction, and unplanned revascularization. According to study results, immediate revascularization was non-inferior to staged revascularization for the primary composite outcome. Those who received immediate revascularization demonstrated lower rates of myocardial infarctions and unplanned ischemia-driven revascularization events. Although this study was well done, it did not compare clinical outcomes between patients who underwent immediate revascularization versus no revascularization to assess the safety and efficacy of this novel procedure.

Click to read the study in The Lancet

Relevant Reading: Percutaneous Revascularization for Ischemic Left Ventricular Dysfunction

In-depth [randomized-controlled trial]: Between Jun 26, 2018, and Oct 21, 2021, 1525 patients were assessed for eligibility at 29 hospitals across 4 countries. Included were patients aged ≥ 18 years with ST-segment elevated myocardial infarction (STEMI) or non-ST-segment elevated myocardial infarction (NSTEMI) and multivessel coronary artery disease using an identifiable culprit artery. Altogether, 764 patients in the immediate revascularization group and 761 patients in the complete revascularization group were included in the final analysis. The primary composite of all-cause mortality, myocardial infarction, and revascularization was non-inferior in the immediate revascularization group (7.6% vs. 9.4%, hazard ratio [HR] 0.78, 95% confidence interval [CI] 0.55-1.11, P for non-inferiority=0.0011) compared to staged revascularization, respectively. There were marked reductions in rates of myocardial infarction (1.9% vs. 4.5%, HR 0.41, 95% CI 0.22-0.76, p=0.0045) and unplanned reperfusion (4.2% vs. 6.7%, HR 0.61, 95% CI 0.39-0.95, p=0.030) in the immediate versus staged revascularization groups, respectively. Findings from this study recommend the clinical use of immediate revascularization for the treatment of patients with multivessel disease-associated acute coronary syndrome.

Image: PD

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