Complete Revascularization in Patients with Acute Coronary Syndrome, Multivessel Disease Reduced Risk of Heart Failure

In patients with acute coronary syndrome (ACS) and multivessel disease, complete revascularization (CR) reduced the risk of hospitalization for heart failure (HF) and both overall and cardiovascular deaths, according to the results of a study published in the Journal of the American Heart Association.

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Investigators use data from the CORALYS registry, an international, multicenter, retrospective study, and enrolled 14,699 patients admitted to the hospital for ACS from 2015 to 2020.

The study included consecutive patients with ACS—both ST-elevation myocardial infarction (STEMI) and non-ST-elevation ACS (NSTE-ACS)—who were treated with primary percutaneous coronary intervention (PCI), according to the investigators. Patients who had multivessel disease were divided into 2 groups, according to revascularization strategy: a CR group and an incomplete revascularization (ICR) group.

The primary endpoint of the study was the composite of first hospitalization for HF or cardiovascular death. Secondary endpoints included the occurrence of a first hospitalization for HF after the index ACS and cardiovascular and all-cause death, the investigators determined.

Of the total patients in the CORALYS registry, 5054 had multivessel disease and were included in the analysis. A total of 1473 (29.2%) of those patients underwent CR, whereas 3581 (70.8%) underwent ICR. The primary endpoint was undergone in 128 (9.2%) patients in the CR group and 575 (16.3%) in the ICR group, the researchers found. The median follow-up time was 2.60 years (IQR, 1.01-4.8 years), and 98% of patients had long-term follow-up data available (1389 CR and 3539 ICR).

In examining the unadjusted Kaplan-Meier time-to-event curves, the CR group had a nonsignificant lower cumulative incidence of the primary endpoint in comparison with the ICR group (hazard ratio [HR], 0.86; 95% CI, 0.70-1.04; P = 0.12). However, after multivariate adjustment, the CR was seen to be significantly associated with a reduced incidence of the primary endpoint (HR, 0.66; 95% CI, 0.51-0.85; P = 0.002), the results of the study show.

Continuing with secondary endpoints, at follow-up, a first HF hospitalization occurred in 88 (6.3%) patients in the CR group and 415 (11.7%) in the ICR group (P < 0.001); cardiovascular death in 51 (3.7%) patients in the CR group and 236 (6.7%) in the ICR (P < 0.001); and all-cause death in 130 (9.4%) patients in the CR group and 531 (15.0%) in the ICR group (P < 0.001), the study investigators determined.

Additionally, CR was associated with a reduced incidence of the primary endpoint in STEMI (HR, 0.59; 95% CI, 0.39-0.89) and NSTE-ACS (HR, 0.71; 95% CI, 0.50-0.99) patients after multivariate adjustment, the results of the study indicated.

The investigators specifically noted that for the NSTE-ACS subgroup, the evidence that a CR is associated with improved outcomes had been more uncertain. There have been previous studies that supported evidence of CR usage in the NSTE-ACS population, and the investigators said their results reaffirm the notion that a CR should be achieved in all patients with ACS and multivessel disease, both in the STEMI and NSTE-ACS subset.

Notably, the researchers said their finding that a CR could mean a reduced risk of a first hospitalization for HF among patients without previously impaired myocardial contractility was somewhat new, as no previous studies had specifically investigated that topic.

The study authors recognized several limitations of their study. Despite the large sample size, this was not a randomized controlled study. Further, the different baseline characteristics of each population were different and could constitute a potential bias due to unmeasured and unknown variables. In addition, data were taken solely from centers in Europe, which could make it difficult to generalize the results to non-European countries.

“When feasible, CR should be performed in all patients with ACS to reduce the incidence of HF and death at follow‐up,” the study authors concluded.

Reference

Bruno F, Marengo G, De Filippo O, et al. Impact of complete revascularization on development of heart failure in patients with acute coronary syndrome and multivessel disease: a subanalysis of the CORALYS registry. J Am Heart Assoc.2023;0:e028475. doi:10.1161/JAHA.122.028475