The prognostic impact of complete revascularization during hospitalization in non-ST elevation myocardial infarction – analysis from the real-life portuguese registry for acute coronary syndromes

Introduction patients with non-ST elevation acute myocardial infarction (NSTEMI) frequently present multivessel disease (MVD) with significant stenosis in non-infarct-related arteries (non-IRA). Unlike for ST elevation acute myocardial infarction, there is a paucity of studies evaluating the prognostic impact of complete revascularization in these patients. In fact, recommendation for complete revascularization is based in observational and non-randomized studies suggesting a possible benefit regarding mortality and major cardiovascular events. Purpose to evaluate the prognostic impact of complete revascularization during the index hospitalization in the Portuguese patients with NSTEMI and MVD. Methods patients hospitalized for NSTEMI with MVD included in a national multicentre retrospective study between October 2010 and December 2022 were divided into two groups: group 1 was submitted to complete percutaneous revascularization during the index hospitalization (IRA and non-IRA with diameter stenosis ≥50% on angiography), and group 2 performed IRA-only revascularization. The impact of complete revascularization on the probability of cardiovascular re-hospitalization, as well as on in-hospital and one-year mortality rates was evaluated. Results a total of 3084 patients was included, 74.8% were males, with a mean age of 67.8±11.9 years. Most patients were submitted to IRA-only revascularization (72.9%). From the remaining, 81.4% performed complete revascularization during the index procedure and 18.6% staged during index hospitalization. Group 1 patients were younger (65.5±11.8 vs. 68.6±11.8 years, p<0.001), with fewer comorbidities and slightly higher left ventricular ejection fraction (55±11 vs. 51±11%, p<0.001). On the other hand, group 2 patients revealed a significantly higher percentage of previous, revascularization (14.8% vs. 1.6%), mostly surgical. Besides overall similar incidence of in-hospital complications, including recurrence of acute myocardial infarction, patients submitted to complete revascularization showed a non-significant trend to an inferior in-hospital mortality rate (0.7 vs. 1.6%, p=0.06). Also, 1-year mortality rate was similar between groups (4.2 vs. 5.0%, p=0.54). However, complete revascularization appeared to result in a long-term prognostic benefit, halving the incidence of unplanned cardiovascular re-hospitalizations at one year of follow-up (9.3 vs. 18.8%, p<0.001). Conclusion complete revascularization led to an overall long-term benefit, mainly due to a reduction in cardiovascular re-hospitalizations, without a significant impact on 1-year mortality rate.

Total revascularization of coronary disease at the time of primary percutaneous coronary intervention.

Complete Versus Culprit-Only Lesion Intervention in Patients With Acute Coronary Syndromes

Association of complete revascularization with safety and outcomes in elderly patients with multi-vessel coronary artery disease: a systematic review and meta-analysis

Complete versus culprit-only revascularization during primary percutaneous coronary intervention in ST-elevation myocardial infarction patients with multivessel disease: A meta-analysis

<h3>Introduction</h3> Acute clinical presentations of coronary artery disease include ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI). Whereas STEMI presentations tend to be due to persistent thrombotic coronary artery occlusion requiring immediate revascularisation, NSTEMI presentations tend to be associated with transient thrombotic occlusion and critical stenosis of the culprit vessel which may initially be managed with aggressive anti-platelet and anti-ischaemic therapy. <h3>Aims</h3> The aim of this study was to compare the annual incidence, demographic characteristics, in-hospital mortality rates, 3-year mortality rates and independent predictors of death in patients presenting with STEMI vs NSTEMI acute coronary syndromes. <h3>Methods</h3> We performed a retrospective study of patients admitted via our casualty department between January and December 2006, with a confirmed diagnosis of STEMI or NSTEMI. All patients had prolonged cardiac chest pain or equivalent ischaemic symptoms associated with a serum troponin T rise. Categorisation into STEMI or NSTEMI was based on typical ECG changes. The variables analysed included age, gender, ethnicity, hypertension, diabetes, hyperlipidaemia, smoking, previous ischaemic heart disease and chronic renal impairment. The rates of coronary angiography, revascularisation, in-hospital death and 3-year death were also assessed. <h3>Results</h3> The study cohort consisted of 111 STEMI and 322 NSTEMI patients with a follow-up period of 3 years. Comparative data are given below in Abstract 124 Tables 1 and 2: The STEMI group were younger and had a higher proportion of men and smokers, whereas the NSTEMI group had a higher prevalence of diabetes, hypertension, previous IHD and chronic renal disease. Although STEMI patients had higher coronary angiographic and revascularisation rates than NSTEMI patients, in-hospital death rates in the two groups were similar. However, the 3-year death rate was more than twofold higher in the NSTEMI compared to STEMI group. Age (p=0.007) was the only independent predictor of 3-year mortality in STEMI patients, whereas age (p&lt;0.001) and chronic renal disease (p&lt;0.001) were independent predictors of death in the NSTEMI group. <h3>Conclusion</h3> In conclusion, our study demonstrates a significant difference in comorbidities, revascularisation rates and 3-year mortality rates among STEMI and NSTEMI patients. NSTEMI patients were older, had more comorbidities and higher death rates than STEMI patients. Age was the most robust independent predictor of death in both groups and chronic renal disease, when present, also asserted an adverse prognostic outcome.

The benefits of fractional flow reserve (FFR)-guided complete coronary revascularization in patients with non-ST-segment elevation myocardial infarction (NSTEMI) and multivessel disease remain unclear. To compare FFR-guided complete revascularization of nonculprit lesions vs culprit-only revascularization in patients with NSTEMI and multivessel disease. This prospective, investigator-initiated, multicenter, international randomized clinical trial was conducted at 9 hospitals in Europe. Patients with NSTEMI and multivessel disease who had successful revascularization of the culprit lesion were enrolled between June 2018 and July 2024, and final follow-up was completed on July 21, 2025. The analysis was conducted on July 28, 2025. Eligibility criteria included the presence of at least 1 stenosis of at least 50% in a nonculprit lesion amendable for revascularization. Patients were randomized to receive either FFR-guided complete or culprit-only revascularization during the index procedure. Staged revascularization within 6 weeks after the index procedure was allowed in the culprit-only group. The primary outcome was a composite of all-cause death, nonfatal myocardial infarction, any revascularization, and stroke at 1 year. Key secondary outcomes included individual components of the primary outcome, net adverse clinical events, all-cause death or nonfatal myocardial infarction, cardiac rehospitalization, and bleeding events. Among 478 randomized patients (mean [SD] age, 65.9 [10.6] years; 347 [72.9%] males), 240 were randomized to receive FFR-guided complete revascularization and 238 were randomized to receive culprit-only revascularization, with crossover occurring in 7 patients in the culprit-only group. The primary outcome occurred in 13 patients (5.5%) in the FFR-guided complete revascularization group vs 32 patients (13.6%) in the culprit-only group (hazard ratio [HR], 0.38 [95% CI, 0.20-0.72]; P = .003). Rates of any revascularization (3.0% vs 11.5%; HR, 0.24 [95% CI, 0.11-0.56]; P < .001) and net adverse clinical events (6.3% vs 15.3%; HR, 0.39 [95% CI, 0.21-0.70]; P = .002) were also significantly lower in the complete revascularization group, while there were no significant differences in the remaining secondary outcomes. FFR-guided complete revascularization during the index procedure resulted in a significant reduction in the composite of all-cause death, nonfatal myocardial infarction, any revascularization, and stroke at 1 year. This was mainly driven by reduced repeat revascularization. ClinicalTrials.gov Identifier: NCT03562572.

Background Complete revascularization has been recently popularized for management of ST-Segment–Elevation Myocardial Infarction (STEMI) patients with multivessel disease scheduled for Primary Percutaneous Coronary Intervention (PPCI). We assessed the three months outcomes of Compete Revascularization (CR) compared to staged revascularization in patients with multivessel disease undergoing PPCI. Materials and methods We conducted a randomized, open-label, comparative trial on STEMI patients with multivessel disease indicated for PPCI in the setting of STEMI. Patients were randomly assigned to undergo PCI revascularization of the non-culprit lesions during the index procedure, Complete Revascularization (CR) or within 30 days later after discharge, Staged Revascularization (SR). The primary endpoint was the composite of all-cause mortality, re-infarction, Heart Failure (HF), recurrence of angina symptoms, cerebrovascular stroke, and need for revascularization. Results A total of 100 patients were randomized in 1:1 ratio. The primary end point occurred in 24% of the patients in CR and 20% in SR group (p = 0.62). The incidence of HF (14% vs. 12%; p = 0.76), repeated revascularization (4% in each group), persistent angina (8% vs. 2%, p = 0.16), all-cause mortality (2% in each group), MI (4% in each group), stent thrombosis (0% vs. 4%; p = 0.15), and cerebrovascular accident (0% vs. 2%; p = 0.32). Conclusion Staged revascularization provided comparable short-term benefits to complete revascularization in STEMI patients with multivessel disease undergoing PPCI. The present trial demonstrated that complete revascularization was associated with a trend towards higher incidence of stent thrombosis and CVA than staged revascularization. Key words: ST-segment&amp;#x96;elevation myocardial infarction, Primary percutaneous coronary intervention, Revascularization, Multivessel disease. Abbreviations: CAD: Coronary Artery Disease; FFR: Fractional Flow Reserve; PCI: Percutaneous Coronary Intervention; PPCI: Primary Percutaneous Coronary Intervention; STEMI: ST-segment–Elevation Myocardial Infarction; CVA: Cerebrovascular Accidents.

Complete vs Culprit-Only Revascularization in Older Patients With Myocardial Infarction With or Without ST-Segment Elevation

Introduction Multivessel disease (MVD) affects 50% of patients with an acute coronary syndrome (ACS) and is associated with poor clinical outcomes and high mortality. There is limited evidence regarding the option of complete revascularisation (CR) in cases of MVD and non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Purpose The purpose is to determine the impact of the type of percutaneous coronary revascularisation on the prevalence of major adverse cardiovascular and cerebrovascular events (MACCE) in patients with MVD and NSTE-ACS. Methods Observational, longitudinal, analytical, ambispective cohort. Patients with NSTE-ACS [non-ST-segment elevation myocardial infarction (NSTEMI) or unstable angina (UA)] and MVD who underwent a revascularisation strategy via percutaneous coronary intervention (PCI) were included, either during the index procedure (IP) or in staged procedures, during the index hospitalisation or deferred periods ≤ 12 months from the first intervention, with a minimum clinical follow-up of one year. Two groups were assigned: the first included patients undergoing CR, either during the IP or in staged procedures, while the second included patients undergoing culprit-only revascularisation (COR). The primary endpoint was the incidence of MACCE, defined as all-cause mortality, cardiac death, reinfarction, repeat coronary revascularisation, rehospitalisation for UA, and stroke at one year. MACCE survival was assessed using Kaplan-Meier curves, and statistical differences between groups were evaluated with the log-rank test. A p-value &amp;lt; 0.05 was considered statistically significant. Results From April 2020 to August 2023, 146 patients were included, NSTEMI (n = 49) and UA (n = 97), of whom 76.7% (n = 112) underwent a CR strategy, while 23.3% (n = 34) received COR. Within the CR group, 67.9% (n = 76) achieved CR during the IP, and 32.1% (n = 36) in staged procedures. According to Kaplan-Meier curves, at one-year, CR showed a lower number of MACCE, with 10.7% in CR (n = 12) and 44.1% in COR (n = 15), (HR 0.286 [95% CI, 0.093–0.878]; log-rank p = 0.0024) (Figure 1-A, Table 1). In the subgroup comparison of both revascularisation strategies (CR and COR), during IP and staged procedures, fewer MACCE were observed in CR performed during the IP (log-rank p = 0.0143) (Figure 1-B). When analysing individual events, CR showed a lower risk of repeat coronary revascularisation (log-rank p = 0.0259). In the evaluation of subgroups undergoing CR, the incidence of MACCE was 7.9% in IP group (n = 6) and 16.7% in staged procedures (n = 6), (HR 0.462 [95% CI, 0.137–1.561]; log-rank p = 0.1706). Conclusions Complete percutaneous coronary revascularisation in patients with NSTE-ACS associated with MVD showed a lower number of MACCE at one-year follow-up compared to COR. The findings support the implementation of a CR strategy, which is associated with greater benefit when performed during the IP, provided this is feasible.MACCE MACCE in revascularisation strategies

Background and aimsRecently, several randomized trials have shown that patients with multivessel disease (MVD) often pursue complete revascularization during percutaneous coronary intervention (PCI) to improve their prognosis. However, the optimal time for the non-culprit artery has been controversial. This study aimed to determine the optimal strategy for revascularization in ST-segment elevation myocardial infarction (STEMI) patients with multivessel coronary artery disease (CAD).MethodsRandomized controlled trials (RCTs) comparing three revascularization strategies [i.e., complete revascularization at the index procedure (CR), complete revascularization as a staged procedure (SR), or culprit-only revascularization (COR)] in STEMI patients with multivessel coronary artery disease were included. We performed both pairwise and network meta-analyses. Network meta-analysis was performed using mixed treatment comparison models.Results17 trials with 8568 patients were included. In the network meta-analysis, the most interesting finding was that staged revascularization increased the risk of major adverse cardiac events (MACE) compared with complete revascularization at the index procedure [odds ratio (OR): 1.93; 95% confidence interval (CI): 1.07–3.49]. In the pairwise meta-analysis, complete revascularization reduced the incidence of MACE [risk ratio (RR): 0.62, 95% CI: 0.48–0.79, p < 0.001], mainly because it reduced the probability of unplanned repeat revascularization (RR: 0.49, 95% CI: 0.33–0.75, p = 0.001). There were no significant differences in all-cause mortality, cardiac mortality, or nonfatal re-myocardial infarction (MI).ConclusionOur analysis suggests that complete revascularization should be performed in STEMI patients with multivessel coronary artery disease, and complete revascularization at the index procedure is superior to staged revascularization in reducing the risk of MACE events.

Background In patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD), complete revascularization (CR) is recommended over culprit-only PCI to reduce adverse cardiovascular outcomes. However, the optimal strategy for CR, whether angiography (Angio)-guided or physiology-guided, remains uncertain. Methods This network meta-analysis included 14 randomized controlled trials (RCTs) with 11,568 patients to compare the efficacy of angio-guided CR, physiology-guided CR, and culprit-only PCI in reducing major adverse cardiovascular events (MACE), all-cause mortality, recurrent myocardial infarction (MI), cardiovascular (CV) death, and unplanned revascularization. The frequentist and Bayesian approaches were applied to assess the effectiveness of each strategy. Results The pairwise meta-analysis showed that angio-guided CR showed superior efficacy, significantly reducing MACE (OR = 0.44; 95% CI: 0.37–0.52), recurrent myocardial infarction, and unplanned revascularization compared to culprit-only PCI. Physiology-guided CR also reduced MACE (OR = 0.64, 95% CI: 0.45–0.91) and unplanned revascularization. The network metanalysis showed that CV death was lower in the physiology-guided CR group (OR 0.56; 95% CI 0.25–1.05), suggesting a protective effect, but the difference did not reach statistical significance. Furthermore, physiology-guided CR was not significantly better than angio-guided CR in most outcomes. Conclusions Angio-guided CR appears to provide the best overall outcomes for patients with STEMI and MVD, outperforming physiology-guided CR in most endpoints. Further large-scale trials are needed to clarify the relative efficacy of angio-guided CR and physiology-guided CR in this patient population.Network plot Results from the network meta-analysis.

Background: In patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD), complete revascularization (CR) is recommended over culprit-only PCI to reduce adverse cardiovascular outcomes. However, the optimal strategy for CR, whether angiography (Angio)-guided or physiology-guided, remains uncertain. Methods: This network meta-analysis included 14 randomized controlled trials (RCTs) with 11,568 patients to compare the efficacy of angio-guided CR, physiology-guided CR, and culprit-only PCI in reducing major adverse cardiovascular events (MACE), all-cause mortality, recurrent myocardial infarction (MI), cardiovascular (CV) death, and unplanned revascularization. The frequentist and Bayesian approaches were applied to assess the effectiveness of each strategy. Results: The pairwise meta-analysis showed that angio-guided CR showed superior efficacy, significantly reducing MACE (OR = 0.44; 95% CI: 0.37-0.52), recurrent myocardial infarction, and unplanned revascularization compared to culprit-only PCI. Physiology-guided CR also reduced MACE (OR = 0.64, 95% CI: 0.45-0.91) and unplanned revascularization. The network metanalysis showed that CV death was lower in the physiology-guided CR group (OR 0.56; 95% CI 0.25-1.05), suggesting a protective effect, but the difference did not reach statistical significance. Furthermore, physiology-guided CR was not significantly better than angio-guided CR in most outcomes. Conclusions: Angio-guided CR appears to provide the best overall outcomes for patients with STEMI and MVD, outperforming physiology-guided CR in most endpoints. Further large-scale trials are needed to clarify the relative efficacy of angio-guided CR and physiology-guided CR in this patient population.

Background: The optimal therapeutic strategy for ST-segment elevation myocardial infarction (STEMI) patients found to have multi-vessel disease (MVD) is controversial but recent data support complete revascularisation (CR). Whether CR should be completed during the index admission or during a second staged admission remains unclear. Our main objective was to measure rates of major adverse cardiovascular events (MACEs) during the waiting period in STEMI patients selected for staged revascularisation (SR), in order to determine the safety of delaying CR. For completeness, we also describe 30-day and long-term outcomes in STEMI patients with MVD who underwent in-hospital CR.Methods: A single-centre retrospective analysis of 931 STEMI patients treated by primary percutaneous coronary intervention (PCI) identified 397 patients with MVD who were haemodynamically stable and presented within 12 hours of chest pain onset. Of these, 191 underwent multi-vessel PCI: 49 during the index admission and 142 patients undergoing a strategy of SR.Results: Our main finding was that waiting period MACE were 2% (three of 142) in patients allocated to SR (at a median of 31 days). In patients allocated to in-hospital CR, 30-day MACE rates were 10% (five of 49). During a median follow up of 39 months, all-cause mortality was 7.0% vs. 28.6%, and cardiac mortality was 2% vs. 8%, in patients allocated to SR or CR, respectively.Conclusions: Patients with STEMI and MVD who, based on clinical judgement, were allocated to a second admission SR strategy had very few adverse events during the waiting period and excellent long-term outcomes.

Culprit-only versus multivessel or complete versus incomplete revascularization in patients with non-ST-segment elevation myocardial infarction and multivessel disease who underwent successful percutaneous coronary intervention using newer-generation drug-eluting stents