In patients with acute coronary syndrome (ACS) and multivessel coronary disease, an immediate complete revascularization strategy was non-inferior to staged complete revascularization for the composite primary outcome. Furthermore, it was associated with lower rates of myocardial infarction and unplanned ischemia-driven revascularization at 1-year follow-up.

This was the overall conclusion from the results of the BIOVASC trial (NCT03621501), which were presented at the 2023 American College of Cardiology annual meeting by Dr. Roberto Diletti.^1,2 He explained that multiple studies have established the clinical benefit of complete revascularization by percutaneous coronary intervention (PCI) compared with a culprit lesion-only PCI. The BIOVACS study aimed to establish the optimal timing for non-culprit lesion revascularization. A total of 1,525 patients from four European countries were randomized to immediate revascularization (N=764) or staged complete revascularization (N=761). Of the participants, 40% had ST-segment elevation myocardial infarction (STEMI), 52% had non-STEMI, and 8% had unstable angina. The primary outcome was a composite of all-cause mortality, MI, any unplanned ischemia-driven revascularization, or cerebrovascular events in the first year following the index procedure.

In the immediate treatment group, 7.6% had a primary endpoint event versus 9.4% in the staged group, meeting non-inferiority criteria (HR, 0.78; P _{non-inferiority} 0.0011). However, in the prespecified analysis of clinical events at 30 days, immediate complete revascularization was superior (2.2% vs 5.8%; HR, 0.38; P _superiority 0.0007).

After 1 year, no difference was seen in all-cause death between the 2 groups (1.9% vs 1.2%; HR, 1.56; P=0.30), but a second MI was less frequent in the immediate treatment group (1.9% vs 4.5%; HR, 0.41; P=0.0045), as were unplanned ischemia-driven revascularizations (4.2% vs 6.7%; HR, 0.61; P=0.030).

Dr. Diletti offered two possible explanations for the high rate of MI in the staged group (4.5%): the operator may have misjudged the culprit lesion, or there are more unstable plaques so that treating only the culprit lesion “does not do the job.”

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