I so wish it were true... “If it seems too good to be true, it probably is”

Patients presenting with an acute coronary syndrome (ACS) without ST-segment elevation have a high rate of recurrent events in the first 12 months after hospitalization [1]. Thus, any strategy to minimize this rate is highly desirable and could reduce the health and economic burden of ~1.5 million people in the US alone. Many factors contribute to the adverse prognosis. A high incidence of advanced age, multi-vessel coronary artery disease (MV CAD) and chronic kidney disease characterizes these patients and differentiates them from patients with stable CAD and those with acute ST-segment elevation myocardial infarction (STEMI). As many patients have MV CAD, the optimal method of revascularization has not been fully clarified. Intuitively, more complete revascularization (CR) would seem to be preferred. Yet, there has not been a randomized clinical trial addressing this clinical scenario and many analyses of selected populations have provided somewhat conflicting results.
Why would then a common-sense approach not show the expected results? Many reasons have been cited, suggesting maybe that we do not quite know the answer. It is likely that some of the lesions treated did not require intervention (functionally not significant), while some of those treated had irreversibly dysfunctional myocardium. It is also possible that many of the non-culprit lesions do not cause death, recurrent infarction or ACS leading to reintervention – the very same endpoints captured in this analysis – but rather manifest as stable angina and lower quality of life.
In this issue of Advances in Interventional Cardiology, Hawranek et al. examined this very topic in a large cohort of such patients [2]. Out of more than 1,500 ACS patients treated over 9 years, 695 (~44%, 70% of whom had a final diagnosis of myocardial infarction) qualified for the study, but we cannot tell what were the main reasons for exclusion, among the list of potential disqualifying characteristics. Nearly 20% of them had complete revascularization (mainly in one stage), while the rest did not. Such an imbalance in the treatment of interest would require complex statistical modeling (such as inverse probability of treatment weighting propensity score) in an attempt to adjust for the obvious differences between the two groups. The authors chose not to do so and applied only a rather conventional multivariable model. The endpoints of interest were the composite of death, non-fatal myocardial...


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