Key result
Culprit-only revascularization increases non-fatal MI risk ~41% versus multivessel revascularization in NSTE-ACS.
Why the study?
Little is known about whether culprit-only revascularization is sufficient or complete revascularization is needed, and the optimal timing of multivessel revascularization in multivessel disease NSTE-ACS.
Does multivessel revascularization (and specifically one-stage vs multistage) improve clinical outcomes compared to culprit-only revascularization in patients with multivessel disease and NSTE-ACS?
Meta-Analysis (n=222,350)
Yes
Does multivessel revascularization (and specifically one-stage vs multistage) improve clinical outcomes compared to culprit-only revascularization in patients with multivessel disease and NSTE-ACS?
Relative Risk: 1.41 (95% CI 1.04–1.91)
Absolute Event Rate: 3.02% vs 1.56%
p-value: p=0.03
In patients with NSTE-ACS and multivessel disease, multivessel revascularization reduces non-fatal MI and repeat revascularization compared to culprit-only PCI, and a one-stage approach reduces all-cause mortality compared to a staged approach.
Supports multivessel over culprit-only revascularization in multivessel NSTE-ACS; extends evidence for lower non-fatal MI risk.
BACKGROUND: Percutaneous coronary intervention (PCI) is a revolutionary breakthrough in saving many lives from myocardial infarction. However, little is known about the PCI strategy in multivessel disease (MVD) Non-ST Elevation Acute Coronary Syndrome (NSTE-ACS) patients. Should complete revascularization be achieved or culprit-only is sufficient, then when the appropriate time of multivessel revascularization is, whether it is staged or immediate. Limited evidence is available on this matter compared to ST-elevation myocardial infarction (STEMI), even though NSTE-ACS patients carry poorer long-term prognoses compared to STEMI. METHODS: A thorough search for appropriate studies was executed across PubMed, Embase, Medline, Science Direct, and Scopus databases until July 4th, 2023. The risk ratio (RR) underwent analysis through Review Manager 5.4. RESULTS: Twenty-six studies with 222,350 MVD NSTE-ACS patients were included. Culprit-only revascularization was significantly related to a higher risk of non-fatal MI (RR: 1.41, 95% CI: 1.04-1.91, p = 0.03, I2: 65%) and all-repeat revascularization (RR 1.86, 95% CI 1.07-3.25, p = 0.03). While multistage multivessel revascularization was related to significantly higher all-cause mortality (RR: 1.73; 95% CI 1.43-2.10; p < 0.01; I2: 0%), TVR repeat (RR 1.38 95% CI 1.11-1.73, I2 = 18%, p = 0.004), and non-TVR repeat (RR 2.59; 95% CI 1,56-4.30; p = 0.0002; I2: 70%). CONCLUSION: Patients with MVD NSTE-ACS treated with multivessel revascularization showed more favorable results than culprit-only. One-stage multivessel revascularization resulted in fewer adverse events than multistage. Additionally, a comprehensive and methodical prospective investigation is required to validate the factors accountable for these outcomes.
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Oktaviono et al. (2025) conducted a meta-analysis in Non-ST Elevation Acute Coronary Syndrome (NSTE-ACS) with multivessel disease (n=222,350). Culprit-only revascularization vs. Multivessel revascularization was evaluated on Non-fatal myocardial infarction (RR 1.41, 95% CI 1.04-1.91, p=0.03). Culprit-only revascularization in patients with multivessel non-ST elevation acute coronary syndrome significantly increased the risk of non-fatal myocardial infarction (RR 1.41) compared to multivessel revascularization.
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