From the Guidelines
For this 70-year-old male with multiple cardiovascular risk factors who presented with an anterior STEMI and remains hypotensive after successful PCI of the culprit LAD lesion, I recommend staging PCI on the RCA and OM1 lesions during the same hospitalization. The patient has had his culprit lesion (100% LAD occlusion) successfully treated with restoration of TIMI 3 flow, but his persistent hypotension suggests hemodynamic compromise that may benefit from complete revascularization before discharge. Since the patient is currently stabilized from his acute presentation but remains hypotensive, allowing 2-3 days for recovery from the initial procedure while optimizing hemodynamics would be prudent before addressing the significant non-culprit lesions (80% mRCA and 90% OM1). This approach balances the risks of contrast nephropathy and procedural complications against the benefit of complete revascularization during the index hospitalization, as supported by the 2021 ACC/AHA/SCAI guideline for coronary artery revascularization 1. The staged in-hospital approach is particularly appropriate given the patient's hemodynamic instability, which suggests that these additional significant stenoses may be contributing to his compromised cardiac output. During the interim period between procedures, the patient should receive optimal medical therapy including dual antiplatelet therapy, statins, and hemodynamic support as needed, in line with the recommendations from the COMPLETE trial 1. Key considerations in this decision include the patient's clinical stability, the complexity of the non-culprit lesions, and the potential risks and benefits of immediate versus staged revascularization, as outlined in the guideline 1. The benefits of staged PCI, including a reduction in major adverse cardiac events (MACE) and the risk of repeat revascularization or re-infarction, should be weighed against the potential risks, such as contrast nephropathy and procedural complications 1. Ultimately, the decision to stage PCI on the RCA and OM1 lesions during the same hospitalization is guided by the principle of optimizing outcomes while minimizing risks, with the goal of improving the patient's morbidity, mortality, and quality of life.
From the Research
Management of Non-Culprit Lesions
The management of non-culprit lesions in a patient with STEMI and multivessel disease is a topic of ongoing debate. The patient in question has a chronic 80% focal mRCA and 90% focal OM 1 stenosis, along with an acute 100% occlusion of the proximal LAD, which has been successfully treated with PCI.
Treatment Options
The following treatment options are available for the non-culprit lesions:
- Perform PCI on RCA and OM1 now (multivessel PCI)
- Stage PCI on RCA and OM1 on later day during same hospitalization (staged in-hospital PCI)
- Stage PCI on RCA and OM1 on later day as outpatient after discharge (staged out-patient PCI)
- Medical management of RCA and OM1 and place IABP now
Evidence-Based Recommendations
According to the available evidence, complete revascularization in the STEMI setting improves clinical outcomes by reducing the risk of reinfarction and urgent revascularization 2. However, the timing and modality of revascularization of non-culprit lesions are still debated. Some studies suggest that an invasive strategy towards non-culprit lesions does not lead to an increase in left ventricular ejection fraction or a reduction in major adverse cardiac events 3. Other studies recommend a staged PCI strategy of non-culprit lesions, achieving complete revascularization, to reduce the rate of recurrent cardiovascular events 4, 5.
Considerations
When deciding on the management of non-culprit lesions, it is essential to consider the patient's clinical status, the severity of the lesions, and the risk of recurrent cardiovascular events. In this case, the patient remains hypotensive after successful PCI of the LAD, which may influence the decision to perform immediate or staged PCI of the non-culprit lesions. The use of functional assessment, such as fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR), may also be considered to guide the decision-making process 3, 5.