Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Non–ST-Elevation Coronary Syndromes and Multivessel Disease: A Systematic Review and Meta-Analysis

There is lack of evidence regarding the optimal revascularization strategy in patients with non–ST-elevation acute coronary syndrome (NSTE-ACS) and multivessel disease (MVD). This systematic review and meta-analysis compares the clinical impact of percutaneous coronary intervention (PCI) with that of coronary artery bypass graft surgery (CABG) in this subset of patients. EMBASE, MEDLINE, and Web of Knowledge were searched for studies including patients with NSTE-ACS and MVD who underwent PCI or CABG up to September 1, 2021. The primary end point of the meta-analysis was all-cause mortality at 1 year. The secondary end points were myocardial infarction (MI), stroke, or repeat revascularization at 1 year. The analysis was conducted using the Mantel-Haenszel random-effects model to calculate the odds ratio (OR) with 95% confidence interval (CI). Four prospective observational studies met the inclusion criteria, including 1,542 patients who underwent CABG and 1,630 patients who underwent PCI. No significant differences were found in terms of all-cause mortality (OR 0.91, 95% CI 0.68 to 1.21, p = 0.51), MI (OR 0.78, 95% CI 0.40 to 1.51, p = 0.46), or stroke (OR 1.54, 95% CI 0.55 to 4.35, p = 0.42) between PCI and CABG. Repeat revascularization was significantly lower in the CABG group (OR 0.21, 95% CI 0.13 to 0.34, p <0.00001). In patients presenting with NSTE-ACS and MVD, 1-year mortality, MI, and stroke were similar between patients treated with either PCI or CABG, but the repeat revascularization rate was higher after PCI. There is lack of evidence regarding the optimal revascularization strategy in patients with non–ST-elevation acute coronary syndrome (NSTE-ACS) and multivessel disease (MVD). This systematic review and meta-analysis compares the clinical impact of percutaneous coronary intervention (PCI) with that of coronary artery bypass graft surgery (CABG) in this subset of patients. EMBASE, MEDLINE, and Web of Knowledge were searched for studies including patients with NSTE-ACS and MVD who underwent PCI or CABG up to September 1, 2021. The primary end point of the meta-analysis was all-cause mortality at 1 year. The secondary end points were myocardial infarction (MI), stroke, or repeat revascularization at 1 year. The analysis was conducted using the Mantel-Haenszel random-effects model to calculate the odds ratio (OR) with 95% confidence interval (CI). Four prospective observational studies met the inclusion criteria, including 1,542 patients who underwent CABG and 1,630 patients who underwent PCI. No significant differences were found in terms of all-cause mortality (OR 0.91, 95% CI 0.68 to 1.21, p = 0.51), MI (OR 0.78, 95% CI 0.40 to 1.51, p = 0.46), or stroke (OR 1.54, 95% CI 0.55 to 4.35, p = 0.42) between PCI and CABG. Repeat revascularization was significantly lower in the CABG group (OR 0.21, 95% CI 0.13 to 0.34, p <0.00001). In patients presenting with NSTE-ACS and MVD, 1-year mortality, MI, and stroke were similar between patients treated with either PCI or CABG, but the repeat revascularization rate was higher after PCI. Coronary artery bypass grafting (CABG) is currently the treatment of choice for stable patients with multivessel disease (MVD), particularly in patients with diabetes or an intermediate-to-high SYNTAX score. This is mainly due to a reduction in repeat revascularizations compared with percutaneous coronary intervention (PCI).1Daemen J Boersma E Flather M Booth J Stables R Rodriguez A Rodriguez-Granillo G Hueb WA Lemos PA Serruys PW. Long-term safety and efficacy of percutaneous coronary intervention with stenting and coronary artery bypass surgery for multivessel coronary artery disease: a meta-analysis with 5-year patient-level data from the ARTS, ERACI-II, MASS-II, and SoS trials.Circulation. 2008; 118: 1146-1154Crossref PubMed Scopus (257) Google Scholar, 2Thuijs DJFM Kappetein AP Serruys PW Mohr FW Morice MC Mack MJ Holmes Jr, DR Curzen N Davierwala P Noack T Milojevic M Dawkins KD da Costa BR Jüni P Head SJ SYNTAX Extended Survival Investigators. Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow-up of the multicentre randomised controlled SYNTAX trial.Lancet. 2019; 394: 1325-1334Abstract Full Text Full Text PDF PubMed Scopus (324) Google Scholar, 3Collet JP Thiele H Barbato E Barthélémy O Bauersachs J Bhatt DL Dendale P Dorobantu M Edvardsen T Folliguet T Gale CP Gilard M Jobs A Jüni P Lambrinou E Lewis BS Mehilli J Meliga E Merkely B Mueller C Roffi M Rutten FH Sibbing D Siontis GCM ESC Scientific Document Group2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation.Eur Heart J. 2021; 42: 1289-1367Crossref PubMed Scopus (1963) Google Scholar, 4Neumann FJ Sousa-Uva M Ahlsson A Alfonso F Banning AP Benedetto U Byrne RA Collet JP Falk V Head SJ Jüni P Kastrati A Koller A Kristensen SD Niebauer J Richter DJ Seferovic PM Sibbing D Stefanini GG Windecker S Yadav R Zembala MO ESC Scientific Document Group2019 ESC/EACTS Guidelines on myocardial revascularization.Eur Heart J. 2018; 40: 87-165Crossref Scopus (3735) Google Scholar Conversely, PCI has been the recommended treatment strategy in patients with acute coronary syndrome (ACS) given the need for an immediate or urgent revascularization.3Collet JP Thiele H Barbato E Barthélémy O Bauersachs J Bhatt DL Dendale P Dorobantu M Edvardsen T Folliguet T Gale CP Gilard M Jobs A Jüni P Lambrinou E Lewis BS Mehilli J Meliga E Merkely B Mueller C Roffi M Rutten FH Sibbing D Siontis GCM ESC Scientific Document Group2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation.Eur Heart J. 2021; 42: 1289-1367Crossref PubMed Scopus (1963) Google Scholar,5Patel MR Calhoon JH Dehmer GJ Grantham JA Maddox TM Maron DJ Smith PK ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2016 Appropriate Use Criteria for Coronary Revascularization in Patients With Acute Coronary Syndromes: a Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society of Thoracic Surgeons.J Am Coll Cardiol. 2017; 69: 570-591Crossref PubMed Scopus (132) Google Scholar In particular, in patients presenting with ST-elevation myocardial infarction (STEMI), primary PCI of the culprit lesion has emerged as a highly effective treatment because there is a mortality benefit related to time until therapy,6Ibanez B James S Agewall S Antunes MJ Bucciarelli-Ducci C Bueno H Caforio ALP Crea F Goudevenos JA Halvorsen S Hindricks G Kastrati A Lenzen MJ Prescott E Roffi M Valgimigli M Varenhorst C Vranckx P Widimský P ESC Scientific Document Group2018 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC).Eur Heart J. 2017; 39: 119-177Crossref Scopus (5768) Google Scholar, 7Keeley EC Boura JA Grines CL. Comparison of primary and facilitated percutaneous coronary interventions for ST-elevation myocardial infarction: quantitative review of randomised trials.Lancet. 2006; 367: 579-588Abstract Full Text Full Text PDF PubMed Scopus (465) Google Scholar, 8Boersma E Primary Coronary Angioplasty vs. Thrombolysis GroupDoes time matter? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients.Eur Heart J. 2006; 27: 779-788Crossref PubMed Scopus (554) Google Scholar, 9Steg PG James SK Atar D Badano LP Blömstrom-Lundqvist C Borger MA Di Mario C Dickstein K Ducrocq G Fernandez-Aviles F Gershlick AH Giannuzzi P Halvorsen S Huber K Juni P Kastrati A Knuuti J Lenzen MJ Mahaffey KW Valgimigli M van ’t Hof A Widimsky P Zahger D Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology (ESC)ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation.Eur Heart J. 2012; 33: 2569-2619Crossref PubMed Scopus (4575) Google Scholar with subsequent percutaneous revascularization appearing to be a reasonable option.10Bravata DM Gienger AL McDonald KM Sundaram V Perez MV Varghese R Kapoor JR Ardehali R Owens DK Hlatky MA. Systematic review: the comparative effectiveness of percutaneous coronary interventions and coronary artery bypass graft surgery.Ann Intern Med. 2007; 147: 703-716Crossref PubMed Scopus (262) Google Scholar, 11Kornowski R Mehran R Dangas G Nikolsky E Assali A Claessen BE Gersh BJ Wong SC Witzenbichler B Guagliumi G Dudek D Fahy M Lansky AJ Stone GW HORIZONS-AMI Trial InvestigatorsPrognostic impact of staged versus "one-time" multivessel percutaneous intervention in acute myocardial infarction: analysis from the HORIZONS-AMI (harmonizing outcomes with revascularization and stents in acute myocardial infarction) trial.J Am Coll Cardiol. 2011; 58: 704-711Crossref PubMed Scopus (222) Google Scholar, 12Politi L Sgura F Rossi R Monopoli D Guerri E Leuzzi C Bursi F Sangiorgi GM Modena MG. A randomised trial of target-vessel versus multi-vessel revascularisation in ST-elevation myocardial infarction: major adverse cardiac events during long-term follow-up.Heart. 2010; 96: 662-667Crossref PubMed Scopus (309) Google Scholar, 13Di Mario C Mara S Flavio A Imad S Antonio M Anna P Emanuela P Stefano DS Angelo R Stefania C Anna F Carmelo C Antonio C Monzini N Bonardi MA Single vs multivessel treatment during primary angioplasty: results of the multicentre randomised HEpacoat for cuLPrit or multivessel stenting for acute myocardial infarction (HELP AMI) Study.Int J Cardiovasc Intervent. 2004; 6: 128-133Crossref PubMed Scopus (230) Google Scholar In particular, in the scenario in which there is MVD STEMI, CABG is rarely advised, even though complex coronary artery disease is a frequent finding.14Rodríguez-Olivares R López-Menéndez J Barca LV Hycka JM Hernández-Antolín R Rodríguez-Roda Stuart J Zamorano Gómez JL Identification of candidates for coronary artery bypass grafting admitted with STEMI and multivessel Disease.Cardiovasc Revasc Med. 2018; 19: 21-26Crossref PubMed Scopus (4) Google Scholar In patients with non–ST-elevation ACS (NSTE-ACS), the prevalence of MVD ranges between 20% and 40%.15Muller DW Topol EJ Ellis SG Sigmon KN Lee K coronary artery disease: a of after for acute myocardial Thrombolysis and in myocardial infarction Heart J. PubMed Scopus Google JA D Grines M M complex coronary in patients with acute myocardial J Med. PubMed Scopus Google Scholar revascularization the MR Calhoon JH Dehmer GJ Grantham JA Maddox TM Maron DJ Smith PK ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2016 Appropriate Use Criteria for Coronary Revascularization in Patients With Acute Coronary Syndromes: a Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society of Thoracic Surgeons.J Am Coll Cardiol. 2017; 69: 570-591Crossref PubMed Scopus (132) Google Scholar but the optimal treatment C S S Kastrati A Morice MC A Stone GW SJ M MJ H C M P P AJ P B M S S Windecker S Jüni with and a 2007; Full Text Full Text PDF PubMed Scopus Google Scholar No randomized controlled trials compared PCI with CABG in which treatment strategy is but a revascularization strategy on the clinical and coronary disease is JP Thiele H Barbato E Barthélémy O Bauersachs J Bhatt DL Dendale P Dorobantu M Edvardsen T Folliguet T Gale CP Gilard M Jobs A Jüni P Lambrinou E Lewis BS Mehilli J Meliga E Merkely B Mueller C Roffi M Rutten FH Sibbing D Siontis GCM ESC Scientific Document Group2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation.Eur Heart J. 2021; 42: 1289-1367Crossref PubMed Scopus (1963) Google Scholar,5Patel MR Calhoon JH Dehmer GJ Grantham JA Maddox TM Maron DJ Smith PK ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2016 Appropriate Use Criteria for Coronary Revascularization in Patients With Acute Coronary Syndromes: a Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society of Thoracic Surgeons.J Am Coll Cardiol. 2017; 69: 570-591Crossref PubMed Scopus (132) Google DM Gienger AL McDonald KM Sundaram V Perez MV Varghese R Kapoor JR Ardehali R Owens DK Hlatky MA. Systematic review: the comparative effectiveness of percutaneous coronary interventions and coronary artery bypass graft surgery.Ann Intern Med. 2007; 147: 703-716Crossref PubMed Scopus (262) Google MA DM Boersma E Booth J D N Flather M Hueb WA J N McDonald KM Rodriguez A Serruys P U Stables Owens DK Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a analysis of data from randomised trials.Lancet. Full Text Full Text PDF PubMed Scopus Google Scholar In this systematic review and compared clinical after CABG or PCI in patients with ACS and This meta-analysis was to for Systematic and and F J. A systematic to an and to 2018; PubMed Google S S AP D MJ an to the for in Systematic 2021; PubMed Scopus Google Scholar The for Systematic and was 1 to September 1, the were searched the of the The EMBASE, MEDLINE, and Web of terms coronary artery bypass and coronary of and results and studies was and from were were in In the of 1 P M L S J C F N S P A PA T S M L J Sousa-Uva M M M JP Coronary artery bypass grafting versus percutaneous coronary intervention in patients with myocardial infarction and left main or multivessel coronary J Cardiol. 2019; Full Text Full Text PDF PubMed Scopus Google Scholar were to 1-year follow-up data of the clinical The inclusion for the studies were patients with NSTE-ACS and MVD, of PCI with CABG for of stents (4) prospective studies or and at 1 The primary end point was all-cause mortality at 1 year. end points myocardial infarction (MI), stroke, and repeat revascularization at 1 year. was and using the of In for The of in including of of from of and of was as or analysis was to the results were the was from the to on the results to of Mantel-Haenszel random-effects using and pooled as odds ratio (OR) and 95% confidence interval is with to random-effects trials using and The be in PubMed Scopus Google Scholar was for with at p the The was for analysis and to A p was The strategy in of studies were in the as in P M L S J C F N S P A PA T S M L J Sousa-Uva M M M JP Coronary artery bypass grafting versus percutaneous coronary intervention in patients with myocardial infarction and left main or multivessel coronary J Cardiol. 2019; Full Text Full Text PDF PubMed Scopus Google M Lee JM R M DW SJ Lee Serruys PW Comparison of of coronary artery bypass grafting versus for acute coronary J Cardiol. 2017; Full Text Full Text PDF PubMed Scopus Google Scholar, Mehran R Lansky AJ G Nikolsky E M MR A Stone versus percutaneous revascularization for multivessel disease in patients with acute coronary analysis from the and Cardiovasc 2010; PubMed Scopus Google Scholar, Mohr R F A K Mehran R Stone versus percutaneous coronary revascularization for multivessel disease in patients with acute coronary analysis from the Acute and Cardiovasc PubMed Scopus Google Scholar, P M P A A Long-term outcomes of patients with multivessel coronary artery disease presenting elevation acute coronary J. 2019; Google Scholar 1 an of and main for CABG versus PCI. The the of from studies and to the studies were prospective and mortality was in MI and stroke were in A of 1,542 patients underwent CABG, and 1,630 patients underwent PCI. The of and coronary was the of the vs of patients of disease of all-cause mortality, myocardial repeat of all-cause mortality, myocardial in a mortality (OR 0.91, 95% CI 0.68 to 1.21, p = 0.51), MI (OR 0.78, 95% CI 0.40 to 1.51, p = 0.46), or stroke (OR 1.54, 95% CI 0.55 to 4.35, p = 0.42) significantly between PCI and CABG Repeat revascularization (OR 0.21, 95% CI 0.13 to 0.34, p was studies and significantly in the PCI group was for all-cause mortality and repeat revascularization = for stroke, was = and for MI, was The analysis on the primary and secondary end P M L S J C F N S P A PA T S M L J Sousa-Uva M M M JP Coronary artery bypass grafting versus percutaneous coronary intervention in patients with myocardial infarction and left main or multivessel coronary J Cardiol. 2019; Full Text Full Text PDF PubMed Scopus Google M Lee JM R M DW SJ Lee Serruys PW Comparison of of coronary artery bypass grafting versus for acute coronary J Cardiol. 2017; Full Text Full Text PDF PubMed Scopus Google Scholar, Mehran R Lansky AJ G Nikolsky E M MR A Stone versus percutaneous revascularization for multivessel disease in patients with acute coronary analysis from the and Cardiovasc 2010; PubMed Scopus Google Scholar, Mohr R F A K Mehran R Stone versus percutaneous coronary revascularization for multivessel disease in patients with acute coronary analysis from the Acute and Cardiovasc PubMed Scopus Google Scholar, P M P A A Long-term outcomes of patients with multivessel coronary artery disease presenting elevation acute coronary J. 2019; Google Scholar of was as in studies and No studies were to a of the of this systematic review and meta-analysis is the to PCI with CABG in patients presenting with NSTE-ACS and The main there was in all-cause mortality, MI, or stroke, and multivessel PCI was with repeat the the European Society of Cardiology that the be in NSTE-ACS and in stable patients with for complex JP Thiele H Barbato E Barthélémy O Bauersachs J Bhatt DL Dendale P Dorobantu M Edvardsen T Folliguet T Gale CP Gilard M Jobs A Jüni P Lambrinou E Lewis BS Mehilli J Meliga E Merkely B Mueller C Roffi M Rutten FH Sibbing D Siontis GCM ESC Scientific Document Group2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation.Eur Heart J. 2021; 42: 1289-1367Crossref PubMed Scopus (1963) Google Scholar results this in with the SYNTAX Coronary versus for Coronary stable patients with MVD, in which significant in all-cause mortality between patients who underwent PCI and who underwent CABG was at 1-year PW Morice MC Kappetein AP A Holmes DR Mack MJ E van M EJ N K Dawkins KD Mohr FW SYNTAX coronary intervention versus bypass grafting for coronary artery J Med. PubMed Scopus Google Scholar and at DJFM Kappetein AP Serruys PW Mohr FW Morice MC Mack MJ Holmes Jr, DR Curzen N Davierwala P Noack T Milojevic M Dawkins KD da Costa BR Jüni P Head SJ SYNTAX Extended Survival Investigators. Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow-up of the multicentre randomised controlled SYNTAX trial.Lancet. 2019; 394: 1325-1334Abstract Full Text Full Text PDF PubMed Scopus (324) Google Scholar the 5-year mortality in stable patients a benefit for CABG PCI in patients with diabetes and SJ Milojevic M J JM Boersma E MJ Flather M V Hlatky MA Hueb WA M T Mohr FW G SJ Rodriguez Stables Stone GW Serruys PW Kappetein after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of 2018; Full Text Full Text PDF PubMed Scopus Google Scholar the of in studies was with a in terms of major adverse cardiac and events which was higher in the PCI MA DM Boersma E Booth J D N Flather M Hueb WA J N McDonald KM Rodriguez A Serruys P U Stables Owens DK Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a analysis of data from randomised trials.Lancet. Full Text Full Text PDF PubMed Scopus Google SJ JM DW SC Lee SJ Lee Lee SJ Lee DJ DS Lee D Trial Investigators. Trial of stents or bypass surgery for coronary J Med. PubMed Scopus Google Scholar though PCI a revascularization and with a of repeat revascularizations compared with CABG, and in patients with Conversely, CABG be with of stroke, acute and M Lee JM R M DW SJ Lee Serruys PW Comparison of of coronary artery bypass grafting versus for acute coronary J Cardiol. 2017; Full Text Full Text PDF PubMed Scopus Google Scholar, Mehran R Lansky AJ G Nikolsky E M MR A Stone versus percutaneous revascularization for multivessel disease in patients with acute coronary analysis from the and Cardiovasc 2010; PubMed Scopus Google Scholar, Mohr R F A K Mehran R Stone versus percutaneous coronary revascularization for multivessel disease in patients with acute coronary analysis from the Acute and Cardiovasc PubMed Scopus Google JA Booth J F Stables The impact of acute coronary syndrome on and after coronary artery bypass surgery versus percutaneous coronary 1-year results from the or surgery Heart J. PubMed Scopus Google Scholar The higher rate of repeat revascularization in the PCI group be due to the of which with M A E R K of stents in and Am Coll Cardiol. 2006; PubMed Scopus Google Scholar In revascularization has a impact on long-term clinical outcomes in patients with multivessel coronary V Serruys PW T T Holmes DR Mack M Morice MC E A T MA Dawkins KD Kappetein AP Mohr of revascularization and with mortality in the between percutaneous coronary intervention with and cardiac surgery trial of the SYNTAX PubMed Scopus Google Scholar and the of coronary has been as the of revascularization in the SYNTAX V Serruys PW Holmes DR Mack M T Morice MC E James S A R MI T MA van Mohr FW Dawkins KD Kappetein AP G Boersma The impact of revascularization on clinical outcomes and with the SYNTAX Percutaneous Coronary with and trial.J Am Coll Cardiol. PubMed Scopus Google Scholar The in coronary PCI and to a reduction in revascularization rate and clinical C G Holmes DR S revascularization in the of impact on adverse Cardiovasc PubMed Scopus Google M Holmes DR G JA S S of of percutaneous coronary intervention revascularization on long-term outcomes in the 2006; PubMed Scopus Google Scholar In the trial a lower of at 1 in CABG that of PCI using B van L G G S R N A N N P O P O F N K J T MJ D Hlatky MA Mahaffey KW M PCI as compared with coronary bypass J Med. PubMed Scopus Google Scholar The of patients for CABG and has There is and of the artery graft or and in of and effective management and to of clinical outcomes in patients who S A B A V R Flather M Benedetto U of grafting in the revascularization Cardiovasc Full Text Full Text PDF PubMed Scopus Google M F Davierwala P Di A N M G M for myocardial 2018; PubMed Scopus Google Scholar PCI versus CABG been without that has been to significantly and clinical is particularly with and A P RA F TM Guagliumi G PM Alfonso F H T MA M MO O Stone GW PCI compared with and with to coronary a randomised controlled trial.Lancet. Full Text Full Text PDF PubMed Scopus Google Scholar comparing with was with significantly lower of and repeat up to SJ D H of 5-year follow-up of the randomized Cardiovasc PubMed Scopus Google J L S S J T F Investigators. outcomes of the trial comparing versus Cardiovasc 2021; PubMed Scopus Google Scholar The SYNTAX trial a lower of at 5-year follow-up that in AP Serruys P N S N van R M J M R C F A N J P A J D A Dudek D T D V E J J outcomes after percutaneous coronary revascularization in patients with three-vessel disease: results of the SYNTAX Heart J. PubMed Scopus Google Scholar using and systematic after The trial a rate of the of cardiac MI, or revascularization was during complex JM or J Med. Google Scholar the trial and trial PCI in complex the of In the A P RA F TM Guagliumi G PM Alfonso F H T MA M MO O Stone GW PCI compared with and with to coronary a randomised controlled trial.Lancet. Full Text Full Text PDF PubMed Scopus Google Scholar in similar rate with the of either or as a highly effective for PCI this a in the between PCI and CABG in patients with MVD, presenting with stable or The trial is a prospective the of PCI to results and in up to patients with stable or NSTE-ACS and MVD including the left has data from the of and in which in the were in patients with ACS and MVD but prospective observational an including the of of for the results were on which the in the even though the studies to this of the studies for this patients with MVD or left main coronary artery the of patients with left main coronary artery disease was is that to and to in MI studies and The studies repeat revascularization a data be In in patients presenting with NSTE-ACS and MVD, coronary revascularization with either PCI or CABG in significant differences in the of all-cause mortality, MI, and revascularization was with a lower rate of repeat The of to with with with with