Complete versus culprit-only revascularization and long-term outcomes in high-risk non-ST-elevation acute coronary syndrome with multivessel disease: a 5-year multicentre landmark analysis

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: High-risk non-ST-elevation acute coronary syndrome (NSTE-ACS) with multivessel coronary artery disease (n=754). Intervention: Complete revascularization percutaneous coronary intervention (CR-PCI) vs. Culprit-only revascularization percutaneous coronary intervention (COR-PCI). Primary outcome: Major adverse cardiac and cerebrovascular events (MACCE: composite of all-cause death, myocardial infarction, stroke, or unplanned revascularisation) (HR 0.74, 95% CI 0.55-0.999, p=0.049).

Q: What does this research mean for the field?

In patients with high-risk non-ST-elevation acute coronary syndrome and multivessel disease, complete revascularization is associated with a lower long-term risk of major adverse cardiac and cerebrovascular events compared with culprit-only revascularization. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Chaofan Ding; Xiaopeng Feng; Longkun Sun; Jiaqing Dou; 璐雪 张; Jianqin Feng; Yongtao Zhang; Bing Yang; Jing Wang; Pengfei Zhang

doi:10.1186/s12872-026-06883-6

October 26, 2026BMC Cardiovascular DisordersOpen Access

Complete versus culprit-only revascularization and long-term outcomes in high-risk non-ST-elevation acute coronary syndrome with multivessel disease: a 5-year multicentre landmark analysis

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Key result

Complete revascularization linked to ~26% lower MACCE risk vs culprit-only PCI in multivessel NSTE-ACS.

HR 0.74
95% CI 0.55-0.999
P=0.049
n=754

Why the study?

Evidence on long-term outcomes after different index PCI strategies in high-risk NSTE-ACS with multivessel disease remained limited.

Does complete revascularisation PCI reduce major adverse cardiac and cerebrovascular events (MACCE) compared to culprit-only revascularisation PCI in patients with high-risk non-ST-elevation acute coronary syndrome and multivessel coronary artery disease?

Key Points

To evaluate the long-term clinical associations and potential temporal variation of complete versus culprit-only percutaneous coronary intervention in patients with high-risk non-ST-elevation acute coronary syndrome and multivessel disease.
Multicentre retrospective cohort study of 754 patients treated across four tertiary centres from 2016 to 2019, categorized into culprit-only revascularisation (COR-PCI, n=375) and complete revascularisation (CR-PCI, n=379).
Covariate balance was achieved using a 25-variable pretreatment propensity score and winsorised stabilised inverse probability of treatment weighting, analyzed via robust Cox models over a median follow-up of 66 months.
MACCE occurred in 133 of 375 patients (35%) in the COR-PCI group versus 91 of 379 patients (24%) in the CR-PCI group; weighted analysis showed a lower hazard with CR-PCI (HR, 0.74; 95% CI, 0.55–0.999; P = 0.049).
No temporal heterogeneity was detected between the 0–12 month interval (HR, 0.70; 95% CI, 0.35–1.42) and subsequent follow-up (HR, 0.75; 95% CI, 0.54–1.04; P = 0.865).
Hazard ratios were 0.61 (95% CI, 0.36–1.05) for myocardial infarction, 0.65 (95% CI, 0.41–1.03) for unplanned revascularisation, and 1.02 (95% CI, 0.43–2.43) for major bleeding, with none meeting statistical significance after multiplicity adjustment.

Study Design

Type

Cohort (n=754)

Multicenter

Yes

Structured PICO

Does complete revascularisation PCI reduce major adverse cardiac and cerebrovascular events (MACCE) compared to culprit-only revascularisation PCI in patients with high-risk non-ST-elevation acute coronary syndrome and multivessel coronary artery disease?

P

Population

754 patients in China (mean age ~62.8 years, 33.2% female) with high-risk NSTE-ACS and multivessel coronary artery disease undergoing PCI, excluding significant left-main disease or planned staged PCI within 6 weeks, followed for a median of 66 months.

E

Exposure

Complete revascularisation percutaneous coronary intervention (CR-PCI; n=379), defined as treatment of all recorded significant stenoses in major coronary arteries (diameter ≥2.5 mm) during the index procedure, using predominantly everolimus- or sirolimus-eluting stents (99.5%) and recommended dual antiplatelet therapy for at least 12 months after discharge.

C

Comparator

Culprit-only revascularisation percutaneous coronary intervention (COR-PCI; n=375), defined as PCI restricted to the culprit lesion with fewer treated than significant stenoses recorded during the index procedure, using predominantly everolimus- or sirolimus-eluting stents (99.5%) and recommended dual antiplatelet therapy for at least 12 months after discharge.

O

Outcome

Major adverse cardiac and cerebrovascular events (MACCE), a composite of all-cause death, myocardial infarction, stroke, or unplanned revascularisation, at a median follow-up of 66 months (interquartile range, 49–83 months), adjudicated by two independent cardiologists.composite

Main Result

Hazard Ratio: 0.74 (95% CI 0.55–0.999)

Absolute Event Rate: 24% vs 35%

p-value: p=0.049

In patients with high-risk NSTE-ACS and multivessel disease, complete revascularisation during index PCI was associated with a modestly lower 5.5-year risk of major adverse cardiac and cerebrovascular events compared to culprit-only PCI without temporal heterogeneity, though the association was sensitive to unmeasured confounding and exclusion of chronic total occlusions.

Limitations

Group classification was defined by final achieved angiographic outcome rather than operator intent, preventing a true intention-to-treat analysis and potentially introducing selection bias.
Limited robustness to unmeasured confounding, as indicated by a confidence-limit E-value of 1.03.
Centre effects were not analysed and all 4 centres were within one national health system in China, potentially limiting generalisability.
Presence of chronic total occlusion (CTO) lesions in the culprit-only arm may conflate strategic choice with anatomical constraint or recanalisation failure.
SYNTAX scores and systematic physiological (FFR) or plaque-imaging measurements were not routinely collected.
Dataset lacked hospital-level quality metrics, costs, patient-reported outcomes, and detailed care delivery variables.
Retrospective observational cohort design with potential for residual unmeasured confounding (confidence-limit E-value of 1.03 suggests relatively weak unmeasured confounding could move the CI to include the null)
Available procedural records did not verify anatomical completeness for all patients labelled CR-PCI, and records were unavailable for 71 patients treated at outside hospitals
Wide confidence intervals limited interpretation of bleeding differences between groups
Residual baseline imbalance (4 variables retained absolute SMDs > 0.10 after weighting) in the sensitivity analysis of patients without chronic total occlusion

Implication

May support complete revascularization in high-risk NSTE-ACS; hypothesis-generating pending RCTs and sensitivity to unmeasured confounding.

Abstract

Evidence on long-term outcomes after different index percutaneous coronary intervention (PCI) strategies remains limited in high-risk non-ST-elevation acute coronary syndrome (NSTE-ACS) with multivessel disease. We examined the associations between recorded PCI strategies and outcomes, including whether the primary association varied over time. This multicentre retrospective cohort included 754 patients treated at four tertiary centres from 2016 to 2019: 375 were classified as culprit-only revascularisation (COR-PCI) and 379 as complete revascularisation (CR-PCI). The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), comprising all-cause death, myocardial infarction, stroke, or unplanned revascularisation. The primary analysis used a 25-variable pretreatment propensity score, winsorised stabilised average-treatment-effect inverse probability weights, and a robust Cox model. We also assessed temporal variation, conducted landmark and sensitivity analyses, and calculated E-values. Median follow-up was 66 months. Group-specific effective sample sizes after weighting were 300.0 in the COR-PCI group and 303.9 in the CR-PCI group. CR-PCI was associated with a lower estimated hazard of MACCE than COR-PCI (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.55–0.999; P = 0.049). HRs were 0.70 (95% CI, 0.35–1.42) during 0–12 months and 0.75 (95% CI, 0.54–1.04) thereafter; temporal heterogeneity was not detected ( P = 0.865). HRs for myocardial infarction, unplanned revascularisation, and major bleeding were 0.61 (95% CI, 0.36–1.05), 0.65 (95% CI, 0.41–1.03), and 1.02 (95% CI, 0.43–2.43), respectively. Excluding patients with recorded total occlusion yielded a MACCE HR of 0.84 (95% CI, 0.60–1.19). E-values were 1.77 for the point estimate and 1.03 for the confidence limit. CR-PCI was associated with a lower estimated hazard of MACCE after weighting, with no evidence of temporal variation.

Discussion

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Cite This Study

Ding et al. (2026) conducted a cohort in High-risk non-ST-elevation acute coronary syndrome (NSTE-ACS) with multivessel coronary artery disease (n=754). Complete revascularization percutaneous coronary intervention (CR-PCI) vs. Culprit-only revascularization percutaneous coronary intervention (COR-PCI) was evaluated on Major adverse cardiac and cerebrovascular events (MACCE: composite of all-cause death, myocardial infarction, stroke, or unplanned revascularisation) (HR 0.74, 95% CI 0.55-0.999, p=0.049). Complete revascularization PCI was associated with a lower long-term hazard of MACCE compared to culprit-only PCI (HR 0.74, 95% CI 0.55-0.999; P=0.049) in high-risk NSTE-ACS with multivessel disease.

synapsesocial.com/papers/6ae13ce6043bfbd6353326c6 https://doi.org/10.1186/s12872-026-06883-6

Topics

Percutaneous coronary intervention

Acute coronary syndrome

Chronic total occlusion PCI

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Complete versus culprit-only revascularization and long-term outcomes in high-risk non-ST-elevation acute coronary syndrome with multivessel disease: a 5-year multicentre landmark analysis

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Topics

Complete versus culprit-only revascularization and long-term outcomes in high-risk non-ST-elevation acute coronary syndrome with multivessel disease: a 5-year multicentre landmark analysis

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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