Nonculprit Lesion Complexity and Timing of Complete Revascularization in Patients Presenting With Acute Coronary Syndrome and Multivessel Disease: Insights From the BIOVASC Trial

BACKGROUND: The optimal timing of complete revascularization for patients with acute coronary syndrome, multivessel disease and complex nonculprit coronary lesions (NCL) remains unclear. METHODS: The BIOVASC trial randomized patients with acute coronary syndrome and multivessel disease to immediate complete revascularization and staged complete revascularization. The primary end point was a composite of all-cause mortality, myocardial infarction, unplanned ischemia-driven revascularization, or cerebrovascular events at 2-year follow-up. In this exploratory post hoc analysis, patients were classified as having complex NCL if at least 1 nonculprit lesion met the following criteria: true bifurcation; severe calcification; lesion length >20 mm; aorto-ostial lesion; left main lesion. We aimed to compare a strategy of immediate complete revascularization and staged complete revascularization in patients presenting with acute coronary syndrome and multivessel disease with complex NCL. Moreover, we sought to compare patients with complex and noncomplex NCLs in terms of clinical outcomes. RESULTS: Among the 1525 patients enrolled in the BIOVASC trial, 550 (36.1%) had a complex NCL. The presence of a complex NCL was associated with a significantly higher incidence of the primary end point compared with noncomplex NCL (adjusted hazard ratio, 1.49 [95% CI, 1.11–2.02]; P =0.01), including spontaneous myocardial infarction (adjusted hazard ratio, 1.86 [95% CI, 1.12–3.09]; P =0.02). In patients with complex NCL, the cumulative incidence of the primary end point was 15.7% in the immediate complete revascularization group and 17.5% in the staged complete revascularization group (hazard ratio, 0.86 [95% CI, 0.57–1.31]; P =0.49). No significant interaction was observed between the presence of a complex NCL and revascularization strategy for the primary end point ( P for interaction=0.40). CONCLUSIONS: In patients with acute coronary syndrome and multivessel disease, patients with complex NCL experienced worse clinical outcomes at 2-year follow-up, driven by higher rates of myocardial infarction. However, no statistically significant interaction was observed between NCL complexity and the effect of immediate complete revascularization versus staged complete revascularization. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03621501.