Complete Revascularization Versus Culprit-Only PCI in Acute Coronary Syndrome and Multivessel Coronary Artery Disease: An Updated Systematic Review and Meta-Analysis of 10,150 Subjects From 11 Randomized Studies.

Background: Approximately half of individuals with acute coronary syndrome (ACS) are affected by multivessel coronary artery disease (CAD), and recent studies in the field have presented conflicting data on effective benefit of complete revascularization. The aim of this study was to investigate the efficacy and safety of multivessel percutaneous coronary intervention (PCI) versus culprit-only PCI in individuals presenting with acute coronary syndrome and multivessel CAD.

Methods and results: Randomized trials on ACS comparing multivessel PCI versus culprit-only PCI were included. The primary efficacy outcome was all-cause death. The primary safety outcomes were major bleeding and contrast induced nephropathy. Secondary ischemic and safety outcomes were also investigated. Subgroup analyses were conducted to investigate the consistency of the effect sizes as a function of age (younger vs older individuals, using a cut-off of 65 years) and of a higher or lower prevalence of diabetic patients (using a cut-off of 20% for each study). A total of 11 randomized trials including 10,150 individuals with a mean follow-up of 21.7 months were included. Compared with cluprit-only PCI, multivessel PCI significantly reduced the risk of all-cause death (risk ratio 0.86, [0.74-1.00], p = 0.047), mainly due to a significant reduction in cardiovascular mortality by 26%. Similarly, the rates of new myocardial infarction and unplanned revascularization were significantly reduced. No increases in major bleeding, contrast induced nephropathy or stroke were observed, with a significantly higher rate of stent thrombosis in complete revascularization group, even if with a low absolute risk (risk ratio 1.69 [1.10, 2.59], p = 0.027). Subgroup analyses revealed a significant interaction for death in studies with higher prevalence of diabetics (p for interaction = 0.029), but no interaction for death with regards of age.

Conclusion: In individuals presenting with ACS and multivessel CAD, complete revascularization was associated with a significant reduction in all-cause mortality, with a lower rate of major ischemic events and no significant increase in major complications. The benefit was particularly evident in diabetic patients.