Complete Revascularization in NSTE-ACS and Multivessel Disease: Clinical Outcomes and Prognostic Implications

Abstract

Non-ST-segment-elevation acute coronary syndrome (NSTE-ACS) often coexists with multivessel coronary artery disease (MVD), complicating treatment decisions. Current guidelines suggest complete revascularization (CR), yet robust evidence in hemodynamically stable patients remains insufficient. However, the comparative benefit of CR over incomplete revascularization (IR) in reducing ischemic events and improving cardiac function in this population is not well established. The aim of this study was to evaluate the impact of CR on all-cause mortality, cardiac death, and ischemic readmissions at 6 and 12 months, as the composite primary outcome, and to assess left ventricular ejection fraction (LVEF) improvement at discharge and hospital length of stay, as secondary outcomes. A total of 282 hemodynamically stable NSTE-ACS patients with MVD were included, of whom 218 (77.3%) underwent CR and 64 (22.7%) IR. The primary composite outcome occurred in 40.6% of IR patients versus 11.0% in the CR group at 6 months (p < 0.001), and 68.8% vs. 22.0% at 12 months (p < 0.001). CR was associated with significantly lower rates of all-cause and cardiac death, myocardial infarction, and unstable angina. Stroke incidence was similar. Event-free survival favored CR. Multivariable analysis identified CR and baseline LVEF as independent predictors of 12-month outcomes (HR for CR: 7.797; 95% CI: 3.961-15.348; p < 0.001; HR for LVEF: 0.959; CI: 0.926-0.994; p = 0.021). These findings strongly support CR as the preferred therapeutic strategy. Future prospective randomized studies are warranted to confirm the results.

Keywords: NSTE-ACS; STEMI; acute coronary syndrome; complete revascularization; left ventricular ejection fraction; multivessel coronary disease.

Figure 1

Forest plot for the composite primary outcome and for each event from the composite primary outcome. Primary outcome, composite of all-cause death, cardiac death, and ischemic readmissions due to unstable angina, myocardial infarction, stroke; UA, unstable angina; MI, myocardial infarction.

Figure 2

Kaplan–Meier event-free survival curves at 12 months for primary outcome, cardiac death, all-cause death, myocardial infarction. CR, complete revascularization; IR, incomplete revascularization; primary outcome, composite of all-cause death, cardiac death, and ischemic readmissions due to unstable angina, myocardial infarction, or stroke.