In patients presenting with ACS and multivessel disease, when do you favor immediate versus delayed complete revascularization?

My approach is to defer the PCI to a few weeks (as outpatient) as long as the patient is asymptomatic and does not have a critical lesion (i.e. greater than 90% stenosis in the proximal LAD, LCX or RCA).

I have been very consistent with this approach and I recall one patient who came back with unstable angina before the planned staged PCI date. The studies have shown that either approach (At the time of initial admission or follow-up outpatient PCI) has similar outcomes.

I think it is prudent t...

So we are all sitting here answering this question with years of training and experience, and patients are somehow going to magically know the medical issues and cardiac issues to make an informed decision? Is this decision based on financial considerations? Do what your training, experience, and studies have shown, you know the medical and cardiac issues, and the patient will not have that ability in a few short weeks.

In 24 years of practice, I have yet to have a patient on the table say: "no ...

While several trials have shown the long-term benefit of complete revascularization after STEMI in hemodynamically stable patients, The MULTISTARS AMI trial addressed this very question. Over 800 hemodynamically stable patients with STEMI and multivessel CAD were randomized to immediate multivessel PCI or PCI of the culprit lesion followed by staged multivessel PCI of the non-culprit lesions within 19-45 days. The trial has limitations, but it showed that staged revascularization was non-inferio...

The COMPLETE trial looked at this very question and now COMPLETE 2 is similarly looking at this question with all ACS patients.

PCI of the non-infarct related vessel can safely be performed during the index hospitalization or within the first six weeks after discharge.

Contrast-related renal issues, LVEF, recurrent anginal equivalent, arrhythmic burden, high-risk professions, etc., also help in decision-making between index hospitalization versus early outpatient non-culprit vessel PCI.