Optimal revascularization strategy in patients with acute coronary syndrome and multivessel disease: insights from a network meta-analysis.

Coronary multivessel disease (MVD) affects approximately 50% of the patients presenting with acute coronary syndrome (ACS). The optimal revascularization strategy after culprit lesion treatment, including the optimal method to select non-culprit lesions amenable to revascularization, remains unsettled. This study sought to compare culprit-only revascularization, angiography-guided complete revascularization, and physiology-guided complete revascularization in multivessel disease (MVD) patients with acute coronary syndrome (ACS). We searched PUBMED and Web of Science for randomized controlled trials investigating outcomes following culprit-only revascularization, angiography-guided complete revascularization or physiology-guided complete revascularization in patients with ACS and MVD. We identified 14 randomized studies and 11,871 participants with ACS and MVD, of whom 5090 underwent culprit-only intervention, 3641 angiography-guided complete revascularization, 3140 physiology-guided complete revascularization). Major adverse cardiac events (MACE) were lower in both angiography- (IRR 0.60, 95%-CI 0.46-0.79) or physiology-guided (IRR 0.65, 95%-CI 0.50-0.85) complete revascularization compared with culprit-only revascularization. P-score for treatment ranking was higher for angiography- (0.834) than physiology-guidance (0.666). The estimated effects for all-cause and cardiovascular death vs. culprit-only revascularization were 0.89 (95%-CI 0.61-1.30) and 0.82 (95%-CI 0.48-1.40) for angiography-guidance, and 0.78 (95%-CI 0.55-1.11) and 0.64 (95%-CI 0.40-1.01) for physiology-guidance, respectively. For both all-cause death and cardiovascular death, the highest benefit was estimated for physiology-guidance (P-scores respectively 0.821 and 0.870). In patients with ACS and MVD, both angiography- and physiology-guided complete revascularization are superior to culprit-only revascularization with respect to MACE reduction. Angiography-guidance and physiology-guidance were comparable for future events prevention.