From the Guidelines
In patients with STEMI, the primary recommendation is to treat the culprit lesion with immediate PCI, while non-culprit lesions should be addressed in a staged manner, unless the patient has cardiogenic shock or complex multivessel disease, in which case a more individualized approach is necessary. When considering the treatment of non-culprit lesions in STEMI patients, several factors come into play, including the patient's hemodynamic stability, the complexity of the lesions, and the potential risks associated with multivessel PCI 1. For hemodynamically stable patients with low-complexity lesions, a staged approach is generally preferred, where the culprit lesion is treated immediately during the primary PCI procedure, and significant non-culprit lesions are addressed in a planned subsequent procedure, typically days to weeks later, as outlined in the 2021 ACC/AHA/SCAI guideline for coronary artery revascularization 1. Key considerations in this decision-making process include:
- The presence of cardiogenic shock, which may necessitate immediate multivessel PCI
- The complexity of the non-culprit lesions, with simpler lesions potentially being treated during the initial procedure
- The patient's overall clinical status, including factors such as renal function and expected contrast volume
- The involvement of a Heart Team in discussing the optimal revascularization strategy, particularly for complex cases or those with significant comorbidities 1. Ultimately, the goal is to balance the need for complete revascularization with the risks associated with more extensive procedures, prioritizing the patient's morbidity, mortality, and quality of life outcomes.
From the Research
Treatment of STEMI with Percutaneous Coronary Intervention (PCI)
- The treatment of ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI) is a well-established practice, with current guidelines recommending PCI as the treatment of choice for STEMI 2.
- Patients with STEMI frequently have obstructive non-culprit lesions, and those with multivessel disease are at increased risk of major adverse cardiac events 2.
Complete Revascularization vs. Culprit-Only Revascularization
- Recent randomized studies, such as PRAMI, CvLPRIT, and DANAMI-3-PRIMULTI, provide encouraging data that suggest potential benefit with complete revascularization in STEMI patients with obstructive non-culprit lesions 2.
- The COMPLETE trial definitively established the benefit of routine, staged, angiographically guided nonculprit lesion PCI in reducing hard clinical outcomes, including the composite of death from cardiovascular causes or new myocardial infarction, with no major safety concerns 3.
- A strategy of complete revascularization with routine nonculprit lesion PCI in suitable lesions should be standard of care in STEMI with multivessel CAD 3.
Timing of Complete Revascularization
- The timing of complete revascularization with multivessel PCI for myocardial infarction remains unknown, but a recent trial found that immediate multivessel PCI was noninferior to staged multivessel PCI with respect to the risk of death from any cause, nonfatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure at 1 year 4.
- Another study found that culprit vessel revascularization prior to complete angiography was associated with a statistically significant decrease in reperfusion times, with no discernible differences in complication rates 5.
Alternative Revascularization Strategies
- Early myocardial surgical revascularization after STEMI in multivessel coronary disease may be an option, with bridge therapy potentially being a solution for managing antiplatelet therapy after recent PCI with stenting 6.
- A retrospective registry found that staged revascularization with PCI of the culprit vessel followed by coronary artery bypass graft (CABG) of nonculprit vessels was feasible and safe, with no death, reinfarction, or cardiovascular events occurring at follow-up 6.