From the Guidelines
For this 70-year-old male with multiple cardiovascular risk factors who presented with an anterior STEMI and was found to have multivessel disease, I recommend staging PCI on the RCA and OM1 lesions during the same hospitalization. The patient has already undergone successful PCI of the culprit LAD lesion with good results (TIMI 3 flow), but remains hypotensive despite being pain-free. Given his hemodynamic instability and the significant stenosis in both the RCA (80%) and OM1 (90%), addressing these lesions during the same hospitalization is appropriate, as suggested by the 2021 ACC/AHA/SCAI guideline for coronary artery revascularization 1. The immediate post-STEMI period is not ideal for non-culprit vessel intervention as the patient needs stabilization, but these significant stenoses should be addressed before discharge to reduce the risk of subsequent events, consistent with the findings of the COMPLETE trial 1. The patient's hypotension suggests compromised cardiac function, possibly from stunning or ischemia, which could be exacerbated by the remaining significant stenoses. Staging the procedures allows time for myocardial recovery from the index event while ensuring complete revascularization during the vulnerable early post-MI period. Some key points to consider in the management of this patient include:
- The importance of optimal medical therapy, including dual antiplatelet therapy, statins, beta-blockers, and ACE inhibitors as tolerated given his hypotension 1
- The need for hemodynamic support if needed while awaiting the staged procedures
- The potential benefits of staging PCI on the RCA and OM1 lesions, including reduced risk of repeat revascularization or re-infarction 1
- The importance of a Heart Team discussion in patients with complex multivessel CAD to determine the best revascularization strategy 1.
From the Research
Management of Non-Culprit Lesions
The management of non-culprit lesions in a patient with acute coronary syndrome, such as the one described, is a complex issue. The patient has a chronic 80% focal right coronary artery (RCA) stenosis and a 90% focal obtuse marginal 1 (OM1) stenosis, in addition to an acute 100% occlusion of the proximal left anterior descending (LAD) artery, which has been successfully treated with percutaneous coronary intervention (PCI) and a drug-eluting stent (DES).
Timing of Revascularization
- The timing of revascularization of non-culprit lesions is still debated, with some studies suggesting that complete revascularization in the STEMI setting improves clinical outcomes by reducing the risk of reinfarction and urgent revascularization 2.
- Other studies have found that an invasive strategy towards non-culprit lesions does not lead to an increase in left ventricular ejection fraction (EF) or a reduction in major adverse cardiac events (MACE) 3.
- Recent evidence has shown that a staged PCI strategy of non-culprit lesions, achieving complete revascularization, significantly reduces the rate of recurrent cardiovascular events compared with a PCI strategy limited to culprit lesion 4.
Staged PCI
- Staged PCI on RCA and OM1 on a later day during the same hospitalization (staged in-hospital PCI) or as an outpatient after discharge (staged out-patient PCI) may be considered, taking into account the stability of the lesions and the technical difficulty of the procedure.
- The decision to perform staged PCI should be guided by angiography, functional assessment, or intracoronary imaging, and should be individualized based on the patient's clinical presentation and risk factors 2, 4, 5.
Medical Management
- Medical management of RCA and OM1, including antiplatelet therapy, statins, beta-blockers, and angiotensin-converting enzyme inhibitors, is essential to reduce the risk of future ischemic events 6.
- The use of intra-aortic balloon pump (IABP) may be considered in patients with cardiogenic shock or severe ischemia, but its use in this patient is not clearly indicated at this time.