Revascularization Strategies in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome (NSTE-ACS) and Severe Coronary Artery Disease

Prior treatment

• Anticipated surgery other than CABG due to severe valvular defect or other structural defect, particularly moderate or severe mitral regurgitation,
• Contraindications to short-term and long-term antiplatelet therapy,
• Previous CABG procedure,
• Previous PCI procedure within the last 6 months,
• Ischemic or hemorrhagic stroke within 6 months prior to inclusion,
• Pregnancy or intention to become pregnant (women of child bearing age must have a recent negative pregnancy test prior to randomization),

Other illness

• ST-segment elevation myocardial infarction (STEMI) or new left bundle branch block (LBBB),
• Stable coronary syndrome,
• Single- or two-vessel coronary disease without involvement of the proximal LAD, defined as narrowing above 50%DS,
• Acute heart failure in class IV (cardiogenic shock),
• End-stage chronic kidney disease on dialysis,
• Non cardiac co-morbidities with life expectancy less than 3 years,

Age

• Age under 18 years,

Other

• Qualification for conservative treatment,
• Need for immediate coronary angioplasty treatment,
• Syntax Score equal or above 33 (\>=33),
• Participation in other clinical trial that have not reached their primary endpoint.

• Subjects must meet ALL of the inclusion criteria to be considered for the trial. If ANY of the exclusion criteria are met, the subject is excluded from the trial and cannot be randomized.
• Age over 18 years,
• Written patient consent,
• Acute Coronary Syndrome without ST-segment elevation of high, intermediate and low risk, including NSTEMI and unstable angina requiring urgent (within 72 hours) invasive strategy,
• Qualification for invasive treatment,
• Multivessel coronary disease, defined as angiographic narrowing \>50%DS on investigator's visual assessment in at least two major coronary artery territories (RCA, LAD, LCX), including involvement of the proximal segment of the left anterior descending artery or three-vessel disease with a Syntax Score \< 33. Intermediate lesions (40-70%) will need to be assessed with either FFR, iFR, or VFFR). Patient may have left main coronary artery disease, defined as narrowing \>50%DS (but this is not obligatory). For borderline changes, IVUS (MLA \<6 mm2 or iFR=\<0,90 or FFR=\<0,80, with an anatomic Syntax Score \<33 will be decisive,
• Feasibility of complete revascularization on both the CABG and PCI sides,
• Consent within the Heart Team for both CABG by the cardiothoracic surgeon and PCI by the interventional cardiologist.