# A riddle of culprit only vs multivessel or immediate vs staged revascularization in patients with non-ST elevation acute coronary syndrome: A meta-analysis

## TL;DR

This study compares different PCI strategies in patients with multivessel non-ST elevation acute coronary syndrome and finds that multivessel revascularization leads to better outcomes than culprit-only approaches.

## Contribution

The study provides new evidence on optimal PCI strategies for multivessel non-ST elevation acute coronary syndrome patients through a meta-analysis.

## Key findings

- Culprit-only revascularization increases the risk of non-fatal MI and repeat revascularization.
- Multistage multivessel revascularization is linked to higher mortality and repeat events.
- One-stage multivessel revascularization results in fewer adverse events compared to multistage.

## Abstract

Percutaneous coronary intervention (PCI) is a revolutionary breakthrough in saving many lives from myocardial infarction. However, little is known about the PCI strategy in multivessel disease (MVD) Non-ST Elevation Acute Coronary Syndrome (NSTE-ACS) patients. Should complete revascularization be achieved or culprit-only is sufficient, then when the appropriate time of multivessel revascularization is, whether it is staged or immediate. Limited evidence is available on this matter compared to ST-elevation myocardial infarction (STEMI), even though NSTE-ACS patients carry poorer long-term prognoses compared to STEMI.

A thorough search for appropriate studies was executed across PubMed, Embase, Medline, Science Direct, and Scopus databases until July 4th, 2023. The risk ratio (RR) underwent analysis through Review Manager 5.4.

Twenty-six studies with 222,350 MVD NSTE-ACS patients were included. Culprit-only revascularization was significantly related to a higher risk of non-fatal MI (RR: 1.41, 95% CI: 1.04-1.91, p = 0.03, I2: 65%) and all-repeat revascularization (RR 1.86, 95% CI 1.07-3.25, p = 0.03). While multistage multivessel revascularization was related to significantly higher all-cause mortality (RR: 1.73; 95% CI 1.43-2.10; p < 0.01; I2: 0%), TVR repeat (RR 1.38 95% CI 1.11-1.73, I2 =  18%, p = 0.004), and non-TVR repeat (RR 2.59; 95% CI 1,56-4.30; p = 0.0002; I2: 70%).

Patients with MVD NSTE-ACS treated with multivessel revascularization showed more favorable results than culprit-only. One-stage multivessel revascularization resulted in fewer adverse events than multistage. Additionally, a comprehensive and methodical prospective investigation is required to validate the factors accountable for these outcomes.