Impact of Coronary Calcification on Complete Revascularization in Patients With Acute Coronary Syndrome and Multivessel Disease

Background: Coronary calcification is a well-known marker of atherosclerotic plaque burden and a determinant of stent under expansion with unfavorable long-term outcomes. Aims: This sub study of the randomized BIOVASC trial aimed to compare immediate complete revascularization (ICR) and staged complete revascularization (SCR) in patients with acute coronary syndrome (ACS) and multi vessel disease (MVD), stratified by calcification of the culprit lesion. Methods: The primary endpoint consisted of a composite of all-cause mortality, myocardial infarction, unplanned ischemia driven revascularization (UIDR) and cerebrovascular events at 2 year follow-up. Secondary endpoints included the individual components of the primary composite and major bleedings. We used cox regression models to relate study endpoints with randomized treatment stratified by calcification of the culprit lesion. Results: The BIOVASC trial enrolled 103 patients with a moderately or severely calcified culprit lesion. The composite primary outcome occurred in 8/57 (14.3%) versus 9/46 (19.7%) patients randomized to ICR and SCR (hazard ratio [HR] 0.66% and 95% confidence interval [CI] 0.25−1.71, p = 0.39). In the non-calcified culprit lesions, there were 83 events in the ICR (12.4%) and 82 events in the SCR (11.9%) (HR 1.01 [0.75−1.37], p = 0.94, P-interaction = 0.42). There was no evidence of a differential effect of ICR vs. SCR on the primary endpoint in relation to culprit lesion calcification (P-interaction = 0.42). Conclusion: No differential treatment effect of ICR versus SCR was observed when comparing the primary composite outcome between calcified and non-calcified culprit lesion.