What is the recommended management for STEMI (ST-Elevation Myocardial Infarction) patients with multivessel disease when PCI (Percutaneous Coronary Intervention) is not immediately feasible, according to the ESC (European Society of Cardiology) ACS (Acute Coronary Syndrome) guideline 2023?

Management of STEMI with Multivessel Disease When PCI is Not Immediately Feasible

No, this guidance is NOT based on the ESC ACS guideline 2023 - the most recent ESC STEMI guideline available is from 2017. The question references a 2023 ESC ACS guideline that does not appear in the provided evidence base. The most current ESC guidance for STEMI management comes from the 2017 ESC Guidelines for the Management of Acute Myocardial Infarction in Patients Presenting with ST-Segment Elevation 1.

Primary Reperfusion Strategy Selection

When primary PCI cannot be performed within 120 minutes of STEMI diagnosis, fibrinolytic therapy should be administered immediately (within 10 minutes of diagnosis) followed by transfer to a PCI-capable center. 1

Decision Algorithm Based on Time to PCI:

• If PCI can be performed ≤120 minutes from first medical contact: Transfer for primary PCI is the preferred strategy 1
• If PCI cannot be performed within 120 minutes: Administer fibrinolytic therapy immediately, preferably in the pre-hospital setting 1
• For patients presenting <12 hours from symptom onset with anticipated PCI delay >120 minutes: Fibrinolytic therapy should be given without contraindications 1

Management of Multivessel Disease in STEMI

Limit primary PCI to the culprit vessel only in hemodynamically stable patients with multivessel disease. 1

Exceptions to Culprit-Only Strategy:

• Cardiogenic shock: Emergency revascularization of all significant lesions is recommended regardless of time delay 1
• Persistent ischemia after culprit vessel PCI: Immediate intervention on non-culprit vessels is indicated 1
• Hemodynamic instability: Complete revascularization should be considered 1

Staged Revascularization Approach:

For stable patients with multivessel disease after successful culprit vessel treatment:

• Perform stress testing or imaging (stress myocardial perfusion scintigraphy, stress echocardiography, PET, or cardiac MRI) to assess ischemia and viability in non-culprit territories 1
• If symptomatic ischemia develops: PCI of non-culprit artery at a separate time is recommended 1
• If intermediate or high-risk findings on noninvasive testing: Staged PCI of non-culprit vessels is reasonable 1

Fibrinolysis-to-PCI Pathway (Pharmaco-Invasive Strategy)

All patients receiving fibrinolytic therapy must be transferred immediately to a PCI-capable center for either rescue PCI or routine early angiography. 1

Post-Fibrinolysis Management Timeline:

• Rescue PCI immediately if fibrinolysis fails (<50% ST-segment resolution at 60-90 minutes) or at any time with hemodynamic/electrical instability 1
• Emergency angiography and PCI for patients developing heart failure or shock 1
• Routine angiography with PCI if indicated between 2-24 hours after successful fibrinolysis 1, 2
• Recurrent ischemia or reocclusion: Emergency angiography and PCI immediately 1

Critical Time Targets

The 2017 ESC guidelines establish these maximum time targets 1:

• First medical contact to ECG: ≤10 minutes
• STEMI diagnosis to fibrinolysis: ≤10 minutes (but as soon as possible)
• First medical contact to primary PCI: ≤120 minutes (≤90 minutes preferred for early presenters)
• Post-fibrinolysis transfer: Immediate, with angiography within 2-24 hours

Important Caveats for Multivessel Disease

Do NOT perform PCI on non-infarct arteries during primary PCI in hemodynamically stable patients - this is a Class III recommendation (harm) in stable patients 1. The evidence shows no benefit and potential harm from immediate complete revascularization in stable patients 1.

Routine PCI of a totally occluded infarct artery >48 hours after STEMI is not indicated in asymptomatic, hemodynamically stable patients with completed infarction 1. The OAT trial demonstrated no benefit from late PCI in stable patients with occluded arteries 1.

Adjunctive Antithrombotic Therapy

For Primary PCI:

• Aspirin 162-325 mg (oral or IV) immediately 3
• Potent P2Y12 inhibitor (prasugrel or ticagrelor preferred over clopidogrel) before or at time of PCI 1, 3

For Fibrinolysis:

• Aspirin (oral or IV) 1
• Clopidogrel in addition to aspirin 1
• Anticoagulation with enoxaparin IV followed by subcutaneous (preferred) or UFH as weight-adjusted bolus and infusion 1

The 2025 ACC/AHA guidelines provide similar recommendations but represent American rather than European guidance 1.