Stenting of Non-IRA in STEMI
Routine revascularization of non-infarct-related artery (non-IRA) lesions should be performed before hospital discharge in hemodynamically stable STEMI patients with multivessel disease, but immediate stenting during the index primary PCI should be reserved only for highly selected low-risk patients with simple lesion anatomy.
Hemodynamically Stable Patients
Staged Approach (Preferred Strategy)
The 2017 ESC guidelines give a Class IIa recommendation for routine revascularization of non-IRA lesions before hospital discharge 1. This staged approach is supported by the strongest evidence:
- Perform primary PCI on the infarct-related artery first 1
- Plan staged PCI of non-IRA lesions during the same hospitalization or within 45 days post-MI 1
- Use FFR or angiographic criteria (≥70% stenosis) to guide non-IRA intervention 1
The DANAMI-3-PRIMULTI trial demonstrated that staged complete revascularization reduced the composite endpoint of death, MI, or ischemia-driven revascularization by 44% (HR 0.56,95% CI 0.38-0.83) compared to culprit-only PCI 1.
Immediate Non-IRA Stenting (Highly Selective)
The 2021 ACC/AHA/SCAI guidelines give only a Class IIb recommendation for immediate multivessel PCI 1. Proceed with immediate non-IRA stenting during index primary PCI only when ALL of the following criteria are met:
- Uncomplicated, successful PCI of the infarct artery 1
- Low-complexity non-IRA lesion anatomy 1
- Normal blood pressure and heart rate 1
- Left ventricular end-diastolic pressure <20 mmHg 1
- No chronic renal insufficiency or acute kidney injury 1
- Expected total contrast volume <3× glomerular filtration rate 1
The PRAMI and CvLPRIT trials showed benefit with immediate multivessel PCI (HR 0.35 and 0.49 respectively for MACE), but these benefits were driven primarily by reduced repeat revascularization, not mortality reduction 1.
Cardiogenic Shock
In patients with STEMI complicated by cardiogenic shock, perform culprit vessel-only PCI 1. This is a Class I recommendation based on the CULPRIT-SHOCK trial, which demonstrated that immediate multivessel PCI in shock increased the risk of death or need for renal replacement therapy 1.
- Treat only the infarct-related artery during the acute procedure 1
- Defer non-IRA revascularization until hemodynamic stabilization 1
- Risks of immediate multivessel PCI include volume overload, contrast nephropathy, and further hemodynamic deterioration 1
Complex Multivessel Disease
For patients with complex multivessel non-culprit disease, involve a Heart Team to discuss CABG versus staged PCI 1. The 2021 ACC/AHA/SCAI guidelines give a Class IIa recommendation for CABG of non-culprit arteries in appropriate candidates 1.
Consider the following factors:
- Suitability of non-culprit arteries for PCI 1
- Coronary complexity and revascularization risk 1
- Extent of myocardium at risk 1
- Patient comorbidities and life expectancy 1
Critical Pitfalls to Avoid
Do not routinely perform immediate multivessel PCI in all STEMI patients 1. The 2015 ACC/AHA/SCAI focused update explicitly changed the recommendation from Class III (Harm) to Class IIb (may be considered), emphasizing careful patient selection 1.
Integrate clinical data before proceeding with immediate multivessel PCI:
Observational data and registry studies previously suggested increased mortality with immediate multivessel PCI 1, though recent randomized trials have shown safety in selected patients. The key is appropriate patient selection.
Evidence Strength and Nuances
While multiple randomized trials (PRAMI, CvLPRIT, DANAMI-3-PRIMULTI, Compare-Acute) demonstrated reduced MACE with complete revascularization, none showed statistically significant reductions in total mortality 1. The benefits were driven by reductions in repeat revascularization and, in PRAMI only, non-fatal MI 1.
Observational studies and network meta-analyses suggest staged PCI may have better outcomes than immediate multivessel PCI 1, though definitive randomized data comparing timing strategies are lacking 1.