What does this research mean for the field?

In patients with NSTE-ACS and multivessel disease, both angiographic and physiology-guided complete revascularization were associated with lower cardiovascular death or myocardial infarction (HR 0.77). Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.SUPPORTS_CONSENSUS.

What question did this study set out to answer?

This research aims to investigate the trends in utilization and outcomes of different revascularization strategies in patients with non-ST-elevation acute coronary syndrome and multivessel disease.

February 8, 2026

Revascularization strategies in non-ST-elevation acute coronary syndrome with multivessel disease temporal trends in utilization and associated outcomes

Key Result

Complete revascularization reduced CV death or MI versus incomplete revascularization (HR 0.77 angio-guided, 0.75 physiology-guided); physiology-guided CR lowered all-cause mortality vs angio (HR 0.82

Key Points

This research aims to investigate the trends in utilization and outcomes of different revascularization strategies in patients with non-ST-elevation acute coronary syndrome and multivessel disease.
Analyzed data from the SWEDEHEART registry for patients undergoing culprit lesion PCI from 2005 to 2021.
Included patients had multivessel disease with non-culprit lesions of at least 50% stenosis.
Compared outcomes of complete revascularization (CR) and incomplete revascularization (IR) using hazard ratios.
Over 53,000 patients analyzed; 50.1% underwent IR, 43.4% angiographically guided CR, and 6.5% physiology-guided CR.
Adoption of CR increased from 45% in 2005 to 62% in 2021.
Both CR methods showed lower risks of cardiovascular death or myocardial infarction compared to IR.

Structured PICO

Does complete revascularization (angiographic or physiology-guided) reduce the composite of cardiovascular death or myocardial infarction in patients with NSTE-ACS and multivessel disease compared to incomplete revascularization?

Population

53,401 patients (median age 70 years; 73% males) undergoing culprit lesion percutaneous coronary intervention (PCI) for non-ST-elevation acute coronary syndrome (NSTE-ACS) with multivessel disease (74% NSTEMI, 26% unstable angina pectoris). Included patients had at least one non-culprit lesion with a ≥50% stenosis grade. Excluded: previous CABG, cardiac arrest, eGFR <30 mL/min/1.73m2, or any serious disease causing deviation from recommended therapies.

Intervention

Complete revascularization (CR), either angiographic-guided or physiology-guided (using fractional flow reserve or resting indices).

Comparator

Incomplete revascularization (IR).

Outcome

Composite of cardiovascular (CV) death or myocardial infarction (MI).composite

In patients with NSTE-ACS and multivessel disease, complete revascularization (whether angiographic or physiology-guided) is associated with a significantly lower risk of cardiovascular death or myocardial infarction compared to incomplete revascularization.

Main Result

Absolute Event Rate: 0% vs 0%

Abstract

Abstract Background There is a lack of large, randomized trials to support the use of angiographic and physiology-guided complete revascularization (CR) vs. incomplete revascularization (IR) in non-ST-elevation acute coronary syndrome (NSTE-ACS) with multivessel disease (MVD). Furthermore, the extent of implementation of these strategies in clinical practice is uncertain. Purpose In patients undergoing culprit lesion percutaneous coronary intervention (PCI) for NSTE-ACS with MVD, we assessed different revascularization strategies in terms of 1) temporal trends in utilization; and 2) associated outcomes. Methods We used SWEDEHEART, the Swedish registry for heart disease and interventions, to identify all patients undergoing culprit lesion PCI with an NSTE-ACS indication between 2005 and 2021. Included patients had at least one non-culprit lesion with a ≥50% stenosis grade. Exclusion criteria were previous CABG, cardiac arrest, eGFR 30 mL/min/1,73m2, or any serious disease causing deviation from recommended therapies. Procedures were defined as physiology-guided if the PCI operator recorded use of fractional flow reserve or resting indices. The primary outcome was a composite of cardiovascular (CV) death or myocardial infarction (MI). Main outcome analyses were landmarked at 15 days post-index, allowing staged procedures within this timeframe to contribute to CR. Overlap weighting was used to balance all measured confounders across treatment arms (standardized mean difference 10%). Results Of 53,401 unique patients (median age 70 years; 73% males) treated with PCI for NSTE-ACS with MVD (74% NSTEMI, 26% unstable angina pectoris), 50.1% underwent IR, 43.4% angio-guided CR, and 6.5% physiology-guided CR. We observed an increased adoption of CR (2005: 45%; 2021: 62%, p-trend0.001) and physiology-guided CR (2013: 4%; 2021: 17%, p-trend0.001). Over a median follow-up of 6.3 years, the overlap weighted risk of a primary event was lower with both angiographic CR vs. IR (hazard ratio HR 0.77, 95% confidence interval CI 0.72-0.82) and physiology-guided CR vs. IR (HR 0.75, 95% CI 0.68-0.84), but did not differ between angiographic CR and physiology-guided CR (HR 1.00, 95% CI 0.90-1.12). These results were consistent when considering only the index procedure and when prolonging the staged procedure landmark up to 90 days. Weighted associations were directionally consistent for secondary outcomes, including MI, CV death, and all-cause mortality, except lower risk of all-cause mortality with physiology-guided CR vs. angiographic CR (HR 0.82 95% CI 0.73-0.92). Conclusion In patients with NSTE-ACS and multivessel disease, the implementation of complete non-culprit revascularization and physiology-guided procedures exhibited an upward trend over time. CR, whether angiographically or physiology-guided, was strongly associated with lower CV death or MI and physiology-guided CR was associated with lower all-cause mortality compared to angiographic CR.

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