Complete revascularization and heart failure risk in acute coronary syndrome across the ejection fraction spectrum: focus on LVEF-dependent effects

Objective To investigate the impact of complete revascularization (CR) versus incomplete revascularization (ICR) on the composite outcome of first hospitalization for heart failure (HF) or cardiovascular death in patients with acute coronary syndrome (ACS) and a left ventricular ejection fraction (LVEF) ≥ 40%. Methods This retrospective study enrolled 1,834 patients with ACS, multivessel disease, and an LVEF ≥ 40% (767 CR and 1,067 ICR). CR was defined as percutaneous coronary intervention (PCI) of all suitable non-culprit lesions during index hospitalization or within 45 days postdischarge. The primary endpoint was the first occurrence of hospitalization for HF or cardiovascular death. At discharge, almost all patients received dual antiplatelet therapy and guideline-directed medical therapy. Result During the follow-up period, 35 of the 767 patients (4.6%) in the CR group and 83 of the 1,067 (7.8%) patients in the ICR group reached the primary endpoint ( p < 0.001). After adjusting for covariates, CR was associated with a lower risk of the primary endpoint in the population with an LVEF <50% [hazard ratio (HR), 0.46; 95% confidence interval (CI), 0.22–0.96]. This benefit was confined to patients with non-ST-segment elevation ACS (NSTE–ACS) (HR 0.41; 95% CI 0.20–0.83) but was not observed in the ST-segment elevation myocardial infarction (STEMI) subgroup. Conclusion CR is associated with a significantly reduced risk of HF hospitalization or cardiovascular death in patients with an LVEF of 40%–50%. This benefit attenuated as the LVEF increased, highlighting a potential LVEF-dependent efficacy. Although these results are promising, the observational nature of this study and the potential for residual confounding necessitate cautious interpretation.