How should non-culprit lesions in the Right Coronary Artery (RCA) and Obtuse Marginal 1 (OM1) be managed in a 70-year-old female with Hypertension (HTN), Hyperlipidemia, and Tobacco abuse, who presented with an acute anterior ST-Elevation Myocardial Infarction (STEMI) and underwent successful Percutaneous Coronary Intervention (PCI) of the Left Anterior Descending (LAD) artery?

From the Guidelines

The best approach for managing the non-culprit lesions in this patient is to stage PCI on the RCA and OM1 on a later day during the same hospitalization (staged in-hospital PCI). This patient has undergone successful PCI of the culprit LAD lesion causing her STEMI, but still has significant stenosis in two other coronary vessels. Given her multiple cardiovascular risk factors (hypertension, hyperlipidemia, and tobacco abuse) and the severity of the non-culprit lesions (80% RCA and 90% OM1), these should be addressed before discharge. The 2021 ACC/AHA/SCAI guideline for coronary artery revascularization recommends staged percutaneous intervention of a significantly stenosed nonculprit artery in patients presenting with STEMI to improve outcomes 1. Some key points to consider in this decision include:

• The patient's hemodynamic and electrical stability after the initial PCI procedure
• The severity of the non-culprit lesions, which are significant and likely to cause future events if left untreated
• The benefits of complete revascularization in reducing the risk of recurrent events, as demonstrated by recent studies 1 Staging the procedures during the same hospitalization allows the patient to recover from the initial intervention while still addressing all significant lesions before discharge, reducing the risk of recurrent events. This approach balances the risks of prolonged procedures against the benefits of complete revascularization, while avoiding the potential complications of simultaneous multivessel PCI during the acute phase of STEMI. In contrast, performing PCI on the RCA and OM1 immediately, or delaying until after discharge, may not be the best approach for this patient, given the potential risks and benefits of each strategy, and the current guideline recommendations 1.

From the Research

Management of Non-Culprit Lesions

The management of non-culprit lesions in patients with ST-elevation myocardial infarction (STEMI) and multivessel disease is a topic of ongoing debate.

• The optimal treatment strategy for non-culprit lesions detected during primary percutaneous coronary intervention (PCI) is not well established 2, 3.
• Some studies suggest that early invasive treatment of non-culprit lesions does not improve long-term outcomes and may even increase the risk of major adverse cardiac events (MACE) 2, 3.
• However, other studies suggest that complete revascularization, including treatment of non-culprit lesions, may improve clinical outcomes by reducing the risk of reinfarction and urgent revascularization 4, 5.

Treatment Options

The following treatment options are available for non-culprit lesions:

• Perform PCI on non-culprit lesions during the index primary PCI (multivessel PCI)
• Stage PCI on non-culprit lesions on a later day during the same hospitalization (staged in-hospital PCI)
• Stage PCI on non-culprit lesions on a later day as an outpatient after discharge (staged out-patient PCI)
• Medical management of non-culprit lesions
• The choice of treatment strategy should be individualized based on patient characteristics, lesion complexity, and clinical presentation 4, 5.

Considerations

When deciding on a treatment strategy for non-culprit lesions, the following considerations should be taken into account:

• The risk of MACE associated with each treatment strategy
• The potential benefits of complete revascularization
• The timing and modality of revascularization of non-culprit lesions
• The use of functional assessment, such as fractional flow reserve (FFR), to guide treatment decisions 2, 3.