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therapy. In the context of complex CAD and anticipated complex PCI, an initial conservative strategy in medically stabilized patients without ongoing symptoms allows time for Heart Team discussion regarding the optimal revascularization strategy.

9.1.4 Balloons and stents

New-generation DES are associated with superior safety and improved efficacy compared with bare metal stents (BMS) and first-generation DES. The Norwegian Coronary Stent Trial (NORSTENT)—the largest clinical trial comparing outcomes of patients treated with newgeneration DES or BMS—reported that the primary endpoint of death or MI was comparable in both treatment groups. Both target lesion revascularization (TLR) and stent thrombosis were reduced in the DES group and there was no treatment effect by ACS presentation interaction for the primary endpoint.463 The COMFORTABLE-AMI (Comparison of Biolimus Eluted From an Erodible Stent Coating With Bare Metal Stents in Acute ST-Elevation Myocardial Infarction) and EXAMINATION (Everolimus-Eluting Stents Versus Bare-Metal Stents in ST Segment Elevation Myocardial Infarction) trials have also reported the clinical superiority of DES over BMS in terms of lower rates of re-infarction, target lesion revascularization, and stent thrombosis.464,465 This clinical benefit was preserved at longer-term followup.466–468 A strategy of drug-coated balloon (DCB) angioplasty without stenting has also been proposed for patients with NSTE-ACS. In the small, prospective, randomized, single-centre REVELATION (REVascularization With PaclitaxEL-Coated Balloon Angioplasty Versus Drug-Eluting Stenting in Acute Myocardial InfarcTION) trial, DCB PCI vs. DES PCI was investigated in 120 patients undergoing PPCI. The primary endpoint of target vessel FFR at 9 months was not significantly different between the two groups.469 In the small PEPCAD NSTEMI (Bare Metal Stent Versus Drug Coated Balloon With Provisional Stenting in Non-ST-Elevation Myocardial Infarction) trial, 210 patients were randomized to compare a DCB with primary stent treatment (BMS or DES).470 During a mean follow-up period of 9.2 months, DCB treatment was non-inferior to treatment with a stent, with a target lesion failure (primary study endpoint) rate of 3.8% vs. 6.6% (P = 0.53). Given the limitations of these studies (in particular, the relatively small sample sizes), the use of DCB in NSTE-ACS requires further investigation in order to better inform future guideline recommendations.471

9.1.5 Embolic protection and microvascular salvage

strategies 9.1.5.1. Thrombus aspiration Large RCTs have failed to demonstrate a clinical benefit with routine manual thrombus aspiration in comparison to conventional PPCI.472– 474 In an individual patient data meta-analysis, thrombus aspiration was associated with fewer CV deaths and with more strokes or transient ischaemic attacks in the subgroup of patients with high thrombus burden (TIMI thrombus Grade 3).475 However, in a sub-analysis from TOTAL (a Trial of routine aspiration ThrOmbecTomy with PCI vs. PCI ALone in patients with STEMI), routine thrombus aspiration did not improve outcomes at 1 year and was also associated with an increased rate of stroke in patients with high thrombus burden.476 In patients with NSTE-ACS and thrombus-containing lesions, PCI with adjunctive thrombus aspiration was not associated with a reduction in MVO 4 days after the index procedure or with fewer MACE after up to 1 year of follow-up.477 Based on these data, routine thrombus aspiration is not recommended, but in cases of large residual thrombus burden after opening the vessel with a guide wire or a balloon, thrombus aspiration may be considered.

9.1.5.2 Interventions to protect the microcirculation

The damage inflicted on the myocardium during AMI is the result of ischaemia and subsequent reperfusion (ischaemia/reperfusion injury). In patient-level pooled analyses, infarct size and MVO are independent predictors of long-term mortality and HF in survivors of STEMI.436,478 Strategies to reduce ischaemia/reperfusion injury in general (and MVO in particular) remain an unmet clinical need. Further information regarding interventions to protect the microcirculation that are under clinical or experimental investigation is presented in the Supplementary data online.

9.2 Coronary artery bypass grafting

9.2.1. Indication and timing of coronary artery bypass grafting in acute coronary syndrome patients There are no dedicated RCTs comparing percutaneous vs. surgical revascularization in patients with ACS. In the setting of STEMI, CABG should be considered only when PPCI is not feasible, particularly in the presence of ongoing ischaemia or large areas of jeopardized myocardium.479 In patients requiring immediate revascularization in the setting of very high-risk NSTE-ACS, PCI is usually preferred for reasons of timeliness, unless concomitant mechanical complications dictate a preference for surgical intervention. In other patients with ACS, the choice of revascularization modality should be made according to the number of diseased vessels and  the general principles of myocardial revascularization.250 In patients with MVD, the choice of revascularization modality will be influenced by the overall anatomical disease complexity and the presence of comorbidities (including diabetes) in patients with low predicted surgical risk and mortality who are considered suitable for either modality. This is based on data from two large-scale individual patient meta-analyses.480,481

9.2.2 Technical considerations specific to acute

coronary syndrome patients The patient profile, including the need for emergency or extremely expeditious revascularization, may influence both the technique of CABG (including on-pump beating heart CABG) and the choice and use of CABG conduits. The need for prompt surgical revascularization in emergency circumstances does not facilitate the use of full arterial revascularization due to the prolonged period required for graft harvesting. Accordingly, the use of total venous graft-based CABG or the use of single left internal mammary artery plus additional venous grafts may be useful in this setting.397

9.3 Spontaneous coronary artery

dissection Spontaneous coronary artery dissection (SCAD) is an infrequent cause of ACS in general but accounts for a significant proportion of ACS cases in young/middle-aged women.482 The pathophysiology underlying SCAD is different to that of Type 1 MI and there are some differences in its management and outcomes. For these reasons, it is of paramount importance that an accurate diagnosis is established. Until evidence from ongoing prospective trials becomes available, patients with SCAD should receive the same pharmacological therapy as other ACS patients.483 Downloaded from academic.oup.com/eurheartj/article/44/38/3720/7243210 by guest on 07 October 2026