Why is this study important?

• Among patients with acute coronary syndrome found to have multivessel coronary artery disease complete revascularization is associated with improved clinical outcomes, however, the optimal timing remains unclear. 
• The randomized, open-label BIOVASC study demonstrated the noninferiority of an immediate complete revascularization strategy as compared with staged revascularization, in patients with ACS found to have multivessel CAD. 

What question was this study supposed to answer?

What is the optimal timing of intervention among patients with acute coronary syndrome in which complete revascularization is pursued? 

What did the study show? 

More than 1,500 patients who presented for acute coronary syndrome with a definitive culprit lesion on angiogram and multivessel coronary artery disease were randomized to either immediate complete revascularization or culprit only intervention with staged revascularization of non-culprit lesions within 30 days. Patients with cardiogenic shock or chronic total occlusions were excluded. Enrolled patients were admitted NSTEMI (51.8%), STEMI (39.9%) or unstable angina (8.3%); adherence to assigned strategy was high (>95%) and complete revascularization achieved in 96% of cases.

The primary outcome- a composite of death, myocardial infarction, unplanned ischemia driven revascularization, or stroke at 1 year occurred in 7.6% of the subjects in the immediate revascularization and 9.4% of the staged revascularization group (HR 0.78, non-inferiority p=.001).

A prespecified analysis of the primary outcome at 30 days indicated immediate complete revascularization was superior to a staged approach (2.2% vs 5.8%, p=.0007), driven predominantly by increased incidence of myocardial infarction and unplanned ischemia driven revascularization. Notable secondary outcomes include similar rates of all-cause death (1.9 vs 1.2%, p=0.3) and decreased risk of myocardial infarction (1.9 vs 4.5%, p=.0045) in the immediate complete revascularization as compared with staged revascularization respectively.  

The BIOVASC study suggests that at one year, an immediate complete revascularization strategy was non-inferior to a staged approach and may be a feasible option for many patients who present with acute coronary syndrome and are found to have multivessel disease. 
 

All editors: Timothy D. Smith, MD, FSCAI