Complete versus culprit-only revascularization and long-term outcomes in high-risk non-ST-elevation acute coronary syndrome with multivessel disease: a 5-year multicentre landmark analysis

Evidence on long-term outcomes after different index percutaneous coronary intervention (PCI) strategies remains limited in high-risk non-ST-elevation acute coronary syndrome (NSTE-ACS) with multivessel disease. We examined the associations between recorded PCI strategies and outcomes, including whether the primary association varied over time. This multicentre retrospective cohort included 754 patients treated at four tertiary centres from 2016 to 2019: 375 were classified as culprit-only revascularisation (COR-PCI) and 379 as complete revascularisation (CR-PCI). The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), comprising all-cause death, myocardial infarction, stroke, or unplanned revascularisation. The primary analysis used a 25-variable pretreatment propensity score, winsorised stabilised average-treatment-effect inverse probability weights, and a robust Cox model. We also assessed temporal variation, conducted landmark and sensitivity analyses, and calculated E-values. Median follow-up was 66 months. Group-specific effective sample sizes after weighting were 300.0 in the COR-PCI group and 303.9 in the CR-PCI group. CR-PCI was associated with a lower estimated hazard of MACCE than COR-PCI (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.55–0.999; P = 0.049). HRs were 0.70 (95% CI, 0.35–1.42) during 0–12 months and 0.75 (95% CI, 0.54–1.04) thereafter; temporal heterogeneity was not detected ( P = 0.865). HRs for myocardial infarction, unplanned revascularisation, and major bleeding were 0.61 (95% CI, 0.36–1.05), 0.65 (95% CI, 0.41–1.03), and 1.02 (95% CI, 0.43–2.43), respectively. Excluding patients with recorded total occlusion yielded a MACCE HR of 0.84 (95% CI, 0.60–1.19). E-values were 1.77 for the point estimate and 1.03 for the confidence limit. CR-PCI was associated with a lower estimated hazard of MACCE after weighting, with no evidence of temporal variation.