Complete revascularization with percutaneous coronary intervention for acute coronary syndromes presenting with multivessel disease.

PURPOSE OF REVIEW: Complete revascularization (CR) by percutaneous coronary intervention (PCI) in acute coronary syndromes with multivessel coronary artery disease (CAD) was previously contraindicated in the absence of cardiogenic shock or high-risk ischemia. Over the last decade, CR has been a focus of recent clinical investigation and practice evolution due to high-quality evidence supporting hard cardiovascular outcome benefit, contributing to a reversal in international guidelines. This review provides concise syntheses of contemporary and emerging randomized evidence underpinning current strategies and unresolved questions regarding patient selection, timing of CR and guidance modalities for the identification and treatment of nonculprit lesions.

RECENT FINDINGS: The randomized evidence base supporting CR with PCI for acute coronary syndromes (ACS) and multivessel CAD has increased recently with large-scale trials comparing immediate versus staged CR and physiology-guided versus angiography-guided CR, including reports of longer-term comparative outcomes. Enough events have recently accrued to enable demonstration of all-cause mortality benefits with CR.

SUMMARY: Contemporary randomized data increasingly support CR with PCI in haemodynamically stable patients. However, ACS type, timing of intervention and method of evaluation still necessitate individualized shared clinical decision-making, and further trials are required to validate the optimal PCI strategies by which to achieve CR in the correct populations.