From the Guidelines
In patients with ST-elevation myocardial infarction (STEMI), the current recommendation is to treat the culprit lesion with primary percutaneous coronary intervention (PCI) immediately, and consider staged percutaneous intervention of significantly stenosed nonculprit arteries to improve outcomes, as supported by the 2023 AHA/ACC clinical performance and quality measures for coronary artery revascularization 1. The approach to non-culprit lesions depends on the clinical scenario, with complete revascularization of significant non-culprit lesions considered either during the index procedure or as a staged procedure within days to weeks after the initial PCI.
- Key considerations for the decision include:
- Lesion complexity
- Patient stability
- Contrast load
- Renal function
- The COMPLETE trial demonstrated a 3-year reduction in the composite endpoint of death or MI with staged PCI of the non-infarct artery performed within 45 days of STEMI, compared with conservative care 1.
- In patients with STEMI and complex multivessel CAD, elective CABG remains an appropriate revascularization option after successful PCI of an infarct artery in patients who meet criteria for CABG, and the decision to proceed with PCI versus CABG of the non-infarct artery should include a Heart Team discussion 1.
- For hemodynamically stable patients, staged PCI of nonculprit lesions is recommended to reduce the risk of future cardiovascular events, whereas in cardiogenic shock or hemodynamic instability, culprit vessel–only primary PCI is recommended as the primary PCI strategy 1.
From the Research
Treatment of STEMI with Percutaneous Coronary Intervention (PCI)
- The treatment of STEMI with PCI is a well-established practice, with the goal of rapidly restoring coronary blood flow to the affected area 2.
- The use of PCI in STEMI patients has been shown to improve outcomes, including reducing mortality and morbidity 2, 3.
Culprit and Non-Culprit Lesions
- The decision to treat both culprit and non-culprit lesions in STEMI patients is not explicitly addressed in the provided studies.
- However, the studies suggest that the primary goal of PCI in STEMI patients is to restore blood flow to the affected area, which implies treating the culprit lesion 2, 3.
- There is no clear evidence to support the routine treatment of non-culprit lesions in STEMI patients, although this may be considered on a case-by-case basis.
Antithrombotic Therapy
- Antithrombotic therapy, including antiplatelet and anticoagulant agents, is a crucial component of STEMI treatment 4, 5.
- The use of dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is recommended for STEMI patients undergoing PCI 6, 4, 5.
- The choice of P2Y12 inhibitor, such as prasugrel or ticagrelor, depends on individual patient factors and clinical circumstances 6, 4, 5.
Clinical Practice
- The management of STEMI patients requires a multidisciplinary approach, including timely restoration of coronary blood flow, antithrombotic therapies, and secondary prevention strategies 3.
- Clinical decisions in STEMI patients should be based on individual patient factors, clinical circumstances, and available evidence 2, 3.