Abstract
Background:
Randomized controlled trials (RCTs) have shown varying results between immediate and staged complete percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) and multivessel disease (MVD). We conducted a meta-analysis to reconcile the findings.
Methods:
Online databases were searched for RCTs comparing immediate vs staged complete PCI in patients presenting with ACS. The outcomes of interest were major adverse cardiovascular events (MACE), all cause death, myocardial infarction (MI), cardiovascular death, stent thrombosis, target vessel revascularization (TVR), cerebrovascular events, bleeding and acute kidney injury (AKI)/contrast induced nephropathy (CIN). Risk ratios (RR) with 95 % confidence intervals (CI) were calculated using the random-effects model.
Results:
Nine RCTs with a total of 3637 patients - 1821 in the immediate PCI group and 1816 in the staged PCI group, were included. The mean age was 64 years, 78 % of patients were men and the mean duration of follow up was 1 year. As compared with staged complete PCI, the immediate PCI group was associated with significant reduction of MI (RR 0.53, 95 % CI 0.36–0.77) and TVR (RR 0.69, 95 % CI 0.53–0.90). The risks of all-cause death, cardiovascular death, MACE, cerebrovascular events, stent thrombosis, bleeding and AKI/CIN were similar in the two groups.
Conclusions:
In ACS patients selected for complete revascularization strategy, multivessel PCI during the index procedure may be associated with significant reduction in the risk of MI and TVR without harm when compared with a staged PCI strategy.
Keywords: Immediate complete percutaneous coronary, intervention (PCI), Staged complete PCI, Acute coronary syndrome (ACS), Multivessel disease (MVD)
1. Introduction
Acute coronary syndrome (ACS) is a major cause of morbidity and mortality, with approximately 673,000 cases reported in 2019 [1]. Multivessel disease (MVD), defined as ≥2 coronary arteries with ≥70 % stenosis, is present in approximately 40 % of patients presenting with acute myocardial infarction (MI) [2–5]. As compared with single vessel disease, MVD is associated with higher risk of mortality and major adverse cardiac events (MACE) [6].
Current guidelines recommend complete revascularization in patients with ST-elevation MI (STEMI) and MVD as opposed to culprit lesion only revascularization [7]. For patients with non-ST segment elevation ACS (NSTE-ACS), revascularization of the non-infarct related arteries (IRAs) is recommended according to individual patient characteristics [8]. Furthermore, the timing of non-culprit vessel percutaneous coronary intervention (PCI) is debated, with a few randomized controlled trials (RCTs) and then meta-analysis showing higher risk of mortality if revascularization of non IRAs was performed at the index procedure in STEMI, as compared with staged revascularization at a later date after the index PCI [9]. This resulted in class I recommendation of staged multivessel PCI in patients with STEMI and MVD, with consideration of complete PCI during the index procedure only in patients with low-complexity MVD (class IIb) [7].
Recently, previous evidence has been challenged by a large RCT by Diletti et al. that has shown immediate complete PCI may be associated with reduced risk of MI and revascularization as compared with staged complete PCI among patients with STEMI or NSTE-ACS [10]. Due to these conflicting findings, we aimed to perform meta-analysis of all the RCTs till date comparing the two complete revascularization strategies (immediate vs staged) in patients with ACS.
2. Methods
We searched multiple online databases, including MEDLINE, Pubmed, Cochrane and Embase, for RCTs published since inception until September 1, 2023 using search terms such as ‘complete PCI’, ‘multivessel PCI’, ‘staged PCI’, ‘STEMI’, and ‘NSTE-ACS’ in various combinations. The inclusion criteria were RCTs comparing immediate complete PCI vs staged complete PCI in patients with ACS and MVD, and studies reporting at least one clinical endpoint of interest. Post-hoc analyses of previous RCTs, non-randomized studies and trials evaluating complete vs culprit lesion only PCI were excluded.
The studies were screened for eligibility, risk of bias was assessed and data was collected by 2 independent reviewers (SS and AG), and any discrepancies were resolved after discussion among the reviewers. Baseline characteristics of included studies and patients were collected -number (N) of patients, timing of staged PCI after the index procedure, major inclusion/exclusion criteria, definition of MACE, follow up duration, mean age, male %, patients with three vessel disease, hypertension (HTN), hyperlipidemia (HLD), diabetes mellitus (DM), smoking, previous MI, previous PCI and Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score. Primary endpoints of interest were all cause death, cardiovascular death, MACE, MI, stent thrombosis, target vessel revascularization (TVR), cerebrovascular events (ischemic or hemorrhagic), bleeding and acute kidney injury (AKI)/contrast induced nephropathy (CIN). Additionally, procedure time (minutes) and contrast volume (ml) used were compared. Subgroup analysis was performed according to the presentation - STEMI and NSTE-ACS, wherever data was available.
This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [11]. For statistical analysis, Cochrane Review Manager, version 5.4 (Cochrane, London, United Kingdom) was used [12]. Pooled risk ratios (RR) and standardized mean difference (SMD) along with 95 % confidence intervals (CI) were calculated for individual clinical endpoints using a random-effects model with the Mantel-Haenszel method. p value <0.05 was considered to be statistically significant. Heterogeneity between the studies was depicted by the I-squared statistic - I2 <25 % minimal, I2 = 25–50 % mild, I2 = 50–75 % moderate and I2 > 75 % significant. Forest plots were generated to compare the immediate and staged complete PCI groups for all the clinical outcomes. Individual trials were excluded from the final results to perform sensitivity analysis.
3. Results
Out of the 1649 studies found on initial search, 9 RCTs were included in the final analysis [10,13–20]. The search strategy is shown in the PRISMA flow diagram (Fig. 1). A total of 3637 patients, with 1821 in the immediate complete PCI group and 1816 in the staged complete PCI group were included (Table 1). The staged PCI procedure was done after a mean period of 18 days and the overall follow up duration was 1 year. Seven studies had patients with STEMI, 1 with NSTEMI and 1 combined (STEMI + NSTE-ACS). Most studies excluded the patients with left main disease and cardiogenic shock.
Fig. 1.
PRISMA 2020 flow diagram depicting the search strategy.
Table 1.
Baseline characteristics of the studies.
| Study | N | Timing of staged PCI (days) | Inclusion criteria | Exclusion criteria | Definition of MACE | Follow up (years) |
|---|---|---|---|---|---|---|
| Ochala 2004 + | I - 48 S - 44 |
27.3 ± 12.8 | STEMI, at least 1 significant stenosis other than IRA | LM stenosis ≥50 %, cardiogenic shock | All cause death, MI, TVR | 0.5 |
| Politi 2010 | I - 65 S - 65 |
56.8 ± 12.9 | STEMI | LM stenosis ≥50 %, cardiogenic shock | All deaths, re-infarction, re-hospitalisation for ACS, repeat revascularization | 2.5 |
| Maamoun 2011 | I - 42 S - 36 |
7 | STEMI, at least 2 diseases coronary arteries | LM CAD, cardiogenic shock | All deaths, recurrent MI, re-hospitalisation for angina, TVR, CVA | 1 |
| Tarasov 2017 | I - 67 S - 69 |
10.1 ± 5.1 | STEMI, significant stenosis of ≥2 coronary arteries | LM stenosis ≥50 %, cardiogenic shock | Cardiac death, MI, TVR | 1 |
| Sardella 2016 | I - 264 S - 263 |
4.76 ± 1.23 | NSTEMI, MVD | CTO, cardiogenic shock | All deaths, re-infarction, re-hospitalisation for angina, TVR, stroke | 1 |
| Nichita-Brendea 2021 | I - 50 S - 50 |
2-3 | STEMI, at least 1 significant stenosis other than IRA | Cardiac arrest, cardiogenic shock | All deaths, MI, stroke, revascularization | 1 |
| Diletti 2023 | I - 764 S - 761 |
15 (4–28) | STEMI or NSTE-ACS, MVD | CTO, cardiogenic shock | All deaths, MI, revascularization, cerebrovascular events | 1 |
| Park 2023 | I - 103 S - 106 |
4.4 (1–11.4) | STEMI, > 2 significant target lesions | Pregnancy, cardiogenic shock | All deaths, recurrent MI, repeat revascularization | 1 |
| Stähli 2023 | I - 418 S - 422 |
37 (30–43) | STEMI, MVD | Prolonged resuscitation >10 min, cardiogenic shock | All deaths, nonfatal MI, stroke, unplanned ischemia-driven revascularization, or hospitalisation for heart failure | 1 |
N - number of patients, PCI - percutaneous coronary intervention, I - immediate multivessel PCI group, S - staged multivessel PCI group, STEMI - ST-segment elevation myocardial infarction, IRA - infarct-related artery, NSTEMI - non–ST-segment elevation myocardial infarction, MVD - multivessel disease, NSTE-ACS - non-ST-segment elevation acute coronary syndrome, LM - left main, CAD - coronary artery disease, CTO - chronic total occlusion, MACE - major adverse cardiac event, MI - myocardial infarction, TVR - target vessel revascularization, ACS - acute coronary syndrome, CVA - cerebrovascular accidents.
Some data obtained from prior meta-analyses.
The mean age of the patients was 64 years, 78 % were men and the average SYNTAX score was 15 (Table 2). For the studies that reported comorbidities, 56 % patients had HTN, 51 % had HLD, 28 % had DM, 41 % were smokers, 13 % had previous MI and 11 % had previous PCI. Approximately 28 % of patients were found to have triple vessel disease. Risk of bias assessment for the included trials is shown in Fig. 2.
Table 2.
Baseline characteristics of the patients.
| Study | Age (years) | Male % | HTN % | HLD % | DM % | Smoker % | Previous MI % | Previous PCI % | Three vessel disease % | SYNTAX score |
|---|---|---|---|---|---|---|---|---|---|---|
| Ochala 2004 + | I - 65 | 72.9 | 52.1 | 81.2 | 31.2 | 37.5 | 29.1 | 16.6 | – | – |
| S - 67 | 75 | 47.7 | 90.9 | 34.1 | 43.1 | 22.7 | 15.9 | |||
| Politi 2010 | I - 64.5 | 76.9 | 49.2 | – | 13.8 | – | – | – | 29.2 | – |
| S - 64.1 | 80 | 64.6 | 18.5 | 44.6 | ||||||
| Maamoun 2011 | I - 54.52 | 95.2 | 38.1 | 57.1 | 40.5 | 52.4 | – | – | 26.2 | – |
| S - 52.33 | 88.9 | 33.3 | 44.4 | 55.6 | 55.6 | 22.2 | ||||
| Tarasov 2017 | I - 58.6 | 71.6 | 94 | – | 23.9 | – | 14.9 | – | 47.8 | 19.1 ± 7.9 |
| S - 59.1 | 62.3 | 88.4 | 20.3 | 5.8 | 44.9 | 18.6 ± 7.1 | ||||
| Sardella 2016 | I - 72 | 78.4 | 73.1 | 57.57 | 37.1 | 45.45 | 26.89 | 15.53 | – | 16 (14–18) |
| S - 73 | 79.46 | 66.15 | 54.37 | 39.5 | 40.68 | 23.57 | 16.73 | 15 (14–18) | ||
| Nichita-Brendea 2021 | – | I - 74 | 40 | – | 24 | 50 | – | – | 26 | 10 (6–12) |
| S - 72 | 48 | 22 | 42 | 20 | 9.487 (7–14) | |||||
| Diletti 2023 | I - 65.7 | 78.3 | 55.4 | 50.5 | 20.7 | 33.4 | 9 | 10.9 | 16 | – |
| S - 65.3 | 77.4 | 51.9 | 52.5 | 21.4 | 31.7 | 11.7 | 15.9 | 20.8 | ||
| Park 2023 | I - 63.3 | 79.6 | 54.3 | 36.8 | 40.7 | 36.8 | 0.9 | 1.9 | 16.5 | – |
| S - 62.2 | 83 | 45.2 | 38.6 | 34.9 | 41.5 | 0.9 | 0 | 20.8 | ||
| Stähli 2023 | I - 66 | 76.8 | 54.5 | 26.8 | 15.8 | 33.9 | 6.7 | 7.9 | – | – |
| S - 64 | 80.8 | 50.2 | 27.1 | 15.4 | 35.4 | 4.8 | 5.5 |
Values in number, percentage (%), mean ± standard deviation (SD) or median (range). I - immediate multivessel PCI group, S - staged multivessel PCI group, HTN - hypertension, HLD - hyperlipidemia, DM - diabetes mellitus, MI - myocardial infarction, PCI - percutaneous coronary intervention, SYNTAX - Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery.
Some data obtained from prior meta-analyses.
Fig. 2.
Risk of bias assessment.
All the studies reported MACE - 183 events in the immediate PCI group (n = 1821) and 246 events in the staged PCI group (n = 1816), with no significant difference observed between the two groups (RR 0.79, 95 % CI 0.62–1.02, p = 0.07) and the trials had mild heterogeneity (I2 = 35 %) (Fig. 3a). Forty-two patients in the immediate PCI group and 79 patients in the staged PCI group had MI at follow-up, with the former strategy being associated with significantly reduced risk (RR 0.53, 95 % CI 0.36–0.77, p = 0.001, I2 = 0 %) (Fig. 3b). Only 5 studies reported data on stent thrombosis, with similar risk noted between immediate and staged PCI groups (RR 1.00, 95 % CI 0.52–1.94, p = 1.00, I2 = 0 %) (Fig. 3c). Patients with ACS undergoing immediate complete PCI had significant reduction of TVR as compared with a staged procedure (RR 0.69, 95 % CI 0.53–0.90, p = 0.005, I2 = 0 %) (Fig. 3d).
Fig. 3.
Forest plot showing comparison of the immediate and staged complete PCI groups. a. Major adverse cardiovascular events (MACE). b. Myocardial infarction (MI). c. Stent thrombosis. d. Target vessel revascularization (TVR).
Of the 5 studies that reported the outcomes, the two PCI strategies had similar risk of cerebrovascular events (RR 0.90, 95 % CI 0.49–1.64, p = 0.72, I2 = 0 %) and bleeding (RR 0.68, 95 % CI 0.31–1.49, p = 0.34, I2 = 50 %) (Fig. 4a and b).
Fig. 4.
Forest plot showing comparison of the immediate and staged complete PCI groups. a. Cerebrovascular events. b. Bleeding.
There was no significant difference observed in the immediate vs staged PCI groups with respect to all cause death in ACS patients (RR 1.13, 95 % CI 0.74–1.73, p = 0.58, I2 = 20 %) (Fig. 5a). The risk of cardiovascular death was also similar in the two PCI groups (RR 1.14, 95 % CI 0.71–1.81, p = 0.59, I2 = 0 %) (Fig. 5b).
Fig. 5.
Forest plot showing comparison of the immediate and staged complete PCI groups. a. All cause death. b. Cardiovascular
We found longer procedure time and greater amount of contrast volume used during the index procedure in the immediate complete PCI group, but no significant difference was observed in the risk of AKI/CIN between the immediate and staged complete PCI strategies (RR 1.12, 95 % CI 0.58–2.14, p = 0.74, I2 = 0 %) (Supplementary figs. 1–3). Subgroup analysis showed that patients with NSTE-ACS had significantly reduced risk of MACE when complete revascularization was performed during the primary PCI as opposed to a staged procedure (RR 0.67, 95 % CI 0.51–0.88, p = 0.004, I2 = 0 %), however the outcomes were similar in patients with STEMI who had immediate vs staged complete PCI (Supplementary figs. 4–11).
Sensitivity analysis for the outcomes is shown in Table 3. Excluding the largest trial by Diletti et al. resulted in the two PCI strategies to have similar risk of MI and TVR [10].
Table 3.
Sensitivity analysis.
| Study | All cause death | MI | Stent thrombosis | TVR | Bleeding | Cardiovascular death | Cerebrovascular events | MACE | AKI/CIN |
|---|---|---|---|---|---|---|---|---|---|
| Final outcome | 1.13 [0.74, 1.73] | 0.53 [0.36, 0.77] | 1.00 [0.52, 1.94] | 0.69 [0.53, 0.90] | 0.68 [0.31, 1.49] | 1.14 [0.71, 1.81] | 0.90 [0.49, 1.64] | 0.79 [0.62, 1.02] | 1.12 [0.58, 2.14] |
| Trials excluded | |||||||||
| Ochala 2004 + | 1.13 [0.74, 1.73] | 0.52 [0.35, 0.78] | – | 0.66 [0.49, 0.87] | – | 1.14 [0.71, 1.81] | – | 0.81 [0.61, 1.08] | – |
| Politi 2010 | 1.12 [0.69, 1.82] | 0.54 [0.36, 0.81] | – | 0.68 [0.52, 0.90] | – | 1.08 [0.67, 1.76] | – | 0.76 [0.58, 0.98] | 1.19 [0.61, 2.35] |
| Maamoun 2011 | 1.14 [0.72, 1.81] | 0.53 [0.36, 0.78] | – | 0.66 [0.51, 0.87] | – | 1.14 [0.71, 1.84] | 0.82 [0.44, 1.53] | 0.76 [0.59, 0.97] | 1.08 [0.55, 2.12] |
| Tarasov 2017 | 1.17 [0.73, 1.88] | 0.48 [0.33, 0.71] | 0.87 [0.42, 1.80] | 0.68 [0.52, 0.88] | – | 1.11 [0.69, 1.78] | – | 0.78 [0.60, 1.02] | – |
| Sardella 2016 | 1.47 [0.94, 2.30] | 0.50 [0.33, 0.76] | 1.00 [0.51, 1.98] | 0.75 [0.55, 1.03] | 0.87 [0.42, 1.81] | 1.49 [0.85, 2.63] | 0.93 [0.50, 1.75] | 0.86 [0.65, 1.14] | 1.12 [0.58, 2.14] |
| Nichita-Brendea 2021 | 1.17 [0.73, 1.88] | – | – | – | 0.68 [0.31, 1.49] | – | – | 0.80 [0.61, 1.04] | 1.12 [0.58, 2.14] |
| Diletti 2023 | 1.07 [0.65, 1.74] | 0.62 [0.38, 1.01] | 1.21 [0.52, 2.83] | 0.75 [0.55, 1.04] | 0.52 [0.29, 0.94] | 1.06 [0.62, 1.80] | 0.87 [0.35, 2.18] | 0.82 [0.60, 1.13] | – |
| Park 2023 | 0.94 [0.65, 1.35] | 0.52 [0.35, 0.76] | 0.94 [0.47, 1.87] | 0.67 [0.52, 0.88] | 0.70 [0.27, 1.86] | 1.02 [0.62, 1.68] | 0.89 [0.48, 1.66] | 0.74 [0.59, 0.94] | 1.12 [0.58, 2.19] |
| Stähli 2023 | 1.20 [0.70, 2.05] | 0.59 [0.38, 0.91] | 1.08 [0.49, 2.41] | 0.67 [0.51, 0.89] | 0.65 [0.18, 2.41] | 1.16 [0.70, 1.94] | 0.98 [0.48, 2.00] | 0.85 [0.67, 1.07] | 0.96 [0.23, 4.00] |
Values are presented in risk ratio [95 % confidence interval]. MACE - major adverse cardiac event, MI - myocardial infarction, TVR - target vessel revascularization, AKI - acute kidney injury, CIN - contrast induced nephropathy.
Some data obtained from prior meta-analyses.
4. Discussion
Our meta-analysis showed that complete revascularization strategy during the index procedure in patients with ACS was superior to staged revascularization strategy in regards to MI and TVR events at a mean follow up of 1 year. Further, patients initially presenting with NSTE-ACS had significant reduction of MACE events with immediate complete PCI when compared with staged PCI, however patients with STEMI had similar outcomes with the two complete PCI strategies. Although procedure time was longer and a greater amount of contrast was used in patients treated with immediate complete PCI, there was no significant difference in the rate of AKI, and this should not impact clinical decisionmaking regarding PCI timing strategy for patients with ACS who are not in cardiogenic shock.
Patients presenting with ACS, who are found to have MVD, are at a higher risk of adverse cardiovascular outcomes than those with single vessel disease [21]. Hence, the current American College of Cardiology/American Heart Association guidelines recommend staged PCI of non-culprit vessels after the primary PCI of culprit lesion in patients with STEMI and MVD who are hemodynamically stable (class 1) [7]. It was proposed that instead of delaying the revascularization of non IRAs to a later date, PCI of the culprit and non-culprit vessels could be performed in a single setting during the index procedure in STEMI which may lead to greater improvement in left ventricular ejection fraction (LV EF) and reduction of hospital stay, as shown in the trial by Ochala et al. (2004) [13]. Subsequent RCT by Tarasov et al. (2017), however, found a higher trend of stent thrombosis if multivessel stenting was done in the primary setting of STEMI as compared with staged procedure [16]. Conversely, Sardella et al. showed significant reduction of MACE in patients with NSTEMI undergoing simultaneous non culprit vessel revascularization during the index procedure [17]. A possible explanation could be a relatively higher pro-inflammatory state in the acute setting of STEMI vs NSTEMI as reflected by the different biomarker concentrations [22].
The largest trial till date by Diletti et al. (BIOVASC, 2023) randomized 1525 patients with ACS to immediate and staged complete revascularization [10]. As compared with the latter, the immediate multivessel PCI group was associated with significant reductions in risk of MI (1.9 % vs 4.5 %) and revascularizations (4.2 % vs 6.7 %) at 1 year. The primary combined endpoint of all deaths, any MI/revascularization or cerebrovascular events was similar in the two groups. Increased risk of MI in the staged revascularization strategy compared with immediate revascularization was driven by more spontaneous MIs in the time period between index event and staged procedure. Furthermore, post-hoc analysis excluding procedure-related MI yielded results consistent with the primary analysis. Importantly, these results were also consistent regardless of the initial presentation (STEMI or NSTEMI). Although chance cannot be ruled out, these findings that contrast with previous studies are likely explained by larger sample size and thus improved power for individual end-points.
Another recent study by Park et al. (2023) of STEMI patients reported similar rates of MACE (hazard ratio [HR] 1.60, 95 % CI 0.65–3.91), MI (1.9 % vs 1.8 %) and revascularization (2.9 % vs 3.7 %) between the immediate (n = 103) vs staged (n = 106) complete PCI groups [19]. The latest trial by Stähli et al. reported noninferiority of immediate as compared with staged multivessel PCI with respect to 1 year risk of all cause death, nonfatal MI, stroke, unplanned ischemia-driven revascularization or heart failure hospitalisation (8.5 % vs 16.3 %, RR 0.52, p <0.001) [20]. More importantly, in line with findings of the BIOVASC trial, rates of MI and ischemia driven revascularization were significantly lower in the immediate revascularization group as compared with staged PCI group.
Our analysis is the largest till date combining all the patients with ACS from RCTs comparing the two strategies for complete revascularization. Previous meta-analyses of only STEMI patients showed opposing results - while some reported increased risk of cardiac death with immediate complete PCI, others reported higher incidence of MACE in the staged PCI group [23–25]. Few key points differentiate our findings from the prior analyses. First, we included the three recent RCTs by Diletti, Park and Stähli et al. which increased our sample size along with the percentage of patients treated with drug eluting stents instead of bare metal stents used in some previous trials [14,15]. Second, we only included RCTs while some of the previous meta-analyses also had observational studies, although subgroup analysis of only RCTs in those studies confirm our findings of no significant difference in the clinical outcomes in STEMI patients with the two multivessel PCI timings [23,24].
Further large scale RCTs are needed to clarify the optimal timing of multivessel PCI in ACS. Some of the ongoing trials are Timing of Complete Revascularization in Patients With ST-segment Elevation Myocardial Infarction And Multivessel Disease (TERMINAL, NCT05231226), Timing of FFR-guided PCI for Non-IRA in STEMI and MVD (OPTION-STEMI, NCT04626882) and Timing of FFR-guided PCI for Non-IRA in NSTEMI and MVD (OPTION-NSTEMI, NCT04968808) [26–28].
There are some important limitations in our results. First, the included trials were heterogeneous in terms of timing of staged procedure after the primary PCI and definition of MACE/MI (Supplementary table 1). Additionally, only a few trials had data on stent thrombosis, cerebrovascular events and bleeding, which may not result in meaningful analysis, especially in the subgroup of STEMI patients. Second, as we did not have access to patient level data, we could not include the trial by Diletti et al. in other clinical outcomes for STEMI patients, apart from MACE. Third, being a trial level analysis, our study carries over the bias from the included RCTs such as selection bias and lack of blinding. Fourth, as only 2 studies had data on NSTEMI, our results may not reflect the real world scenario due to small sample size.
In conclusion, we found that immediate multivessel PCI may be associated with significant reduction in the risk of MI and TVR in patients with ACS when compared with staged multivessel PCI. However, this benefit was nullified when the trial by Diletti et al. was excluded, thereby limiting the clinical impact of the results. More trials of patients with NSTE-ACS are needed to evaluate whether immediate complete PCI is advantageous to staged complete PCI in this group of patients.
Supplementary Material
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of competing interest
Rahul Chaudhary receives T32 grant T32HL129964.
Rest of the authors declare that there is no conflict of interest.
Footnotes
CRediT authorship contribution statement
Sahib Singh: Conceptualization, Methodology, Software, Data curation, Formal analysis, Writing – original draft. Aakash Garg: Data curation, Writing – review & editing. Rahul Chaudhary: Writing – review & editing. Amit Rout: Writing – review & editing. Udaya S. Tantry: Writing – review & editing. Kevin Bliden: Writing – review & editing. Paul A. Gurbel: Writing – review & editing.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.org/10.1016/j.carrev.2023.10.005.
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