Timing of revascularisation in acute coronary syndromes with multivessel disease – two sides of the same coin

About half of patients with ST-segment elevation myocardial infarction (STEMI) and two-thirds of patients with non-ST-segment elevation myocardial infarction (NSTEMI) present with multivessel coronary artery disease, and these patients are at high risk of adverse cardiovascular events1. In haemodynamically stable patients with acute coronary syndromes (ACS) and multivessel coronary artery disease, the benefits of complete revascularisation over culprit-lesion only percutaneous coronary intervention (PCI) have been demonstrated, and complete revascularisation is recommended by contemporary European Society of Cardiology (ESC) guidelines2345. Complete revascularisation in ACS patients can either be performed during the index procedure or as a staged intervention. The optimal timing of complete revascularisation in ACS patients has been recently investigated in two trials: the MULTIvessel Immediate Versus STAged RevaScularization in Acute Myocardial Infarction (MULTISTARS AMI) and the Direct Complete Versus Staged Complete Revascularization in Patients Presenting with Acute Coronary Syndrome and Multivessel Disease (BIOVASC) trials67. Both studies were designed to investigate whether immediate multivessel PCI (performed during the index procedure following primary PCI of the culprit lesion) was non-inferior to staged multivessel PCI...