Long-term outcomes after immediate versus staged complete revascularisation in STEMI or NSTE-ACS

Published in Congress: EuroPCR 2024

Dr. Özkan Bekler

Introduction: Recent randomized studies suggest that immediate complete revascularization (ICR) may be a feasible option compared to staged complete revascularization (SCR) in patients with acute coronary syndrome (ACS) and multivessel disease. However, the long-term effects of ICR have yet to be evaluated in patients with ST-segment elevation acute coronary syndrome (STEMI) and non-ST-segment elevation acute coronary syndrome (NSTEMI).

Objective: This study aims to evaluate the 1-year clinical outcomes of ICR versus SCR in patients with ACS and multivessel disease.

Methods: This is a prospective, randomized, controlled trial involving patients with ACS and multivessel disease characterized by two or more coronary arteries with ≥70% stenosis. A total of 1525 patients were randomized to undergo ICR during the index procedure (n=764) or SCR within 6 weeks of the index procedure (n=761). The number of patients with STEMI was 608, while those with NSTEMI numbered 917. The primary composite endpoint was all-cause mortality, myocardial infarction (MI), any unplanned ischemia-driven revascularization, and cerebrovascular events.
Results: A total of 1525 patients were enrolled from 83 centers in 13 countries. At the 2-year follow-up, the primary composite endpoint occurred in 10.9% of the ICR group and 11.7% of the SCR group. There was no significant difference in the primary composite endpoint between the ICR and SCR groups in both the STEMI and NSTEMI populations. However, in the NSTEMI population, ICR was associated with a significant increase in the risk of the primary endpoint 365 days after the index PCI.

Conclusion: In patients with ACS and multivessel disease, there was no differential treatment effect between ICR and SCR regarding the primary composite endpoint. However, in the NSTEMI population, ICR was associated with a significant increase in the risk of the primary endpoint one year later.

Commentary: This study suggests that while immediate complete revascularization may not differ from staged complete revascularization in terms of short-term clinical outcomes, there is a potential risk for adverse long-term outcomes, particularly in the NSTEMI population. When procedural characteristics were examined, it was observed that the use of FFR/iFR and IVUS/OCT was significantly higher in patients undergoing staged complete revascularization compared to those undergoing immediate complete revascularization. The p-values for FFR/iFR and IVUS/OCT usage were 0.11 and 0.012, respectively, in the STEMI population, and <0.001 for both in the NSTEMI group. The use of FFR/iFR and IVUS/OCT in NSTEMI patients may have contributed to these findings. Long-term outcomes of the study need to be observed.