Complete revascularization in STEMI and multivessel coronary artery disease: In search of the best strategy.

ST-segment elevation myocardial infarction (STEMI) represents one of the most common causes of morbidity and mortality in the worldwide today [ [1] Ibanez B. James S. Agewall S. Antunes M.J. Bucciarelli-Ducci C. Bueno H. et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European society of cardiology (ESC). Eur. Heart J. 2018; 39: 119-177https://doi.org/10.1093/eurheartj/ehx393 Crossref PubMed Scopus (6658) Google Scholar ]. Primary percutaneous coronary intervention (PCI) of the culprit lesion for myocardial reperfusion is the standard-of-care management in STEMI [ [1] Ibanez B. James S. Agewall S. Antunes M.J. Bucciarelli-Ducci C. Bueno H. et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European society of cardiology (ESC). Eur. Heart J. 2018; 39: 119-177https://doi.org/10.1093/eurheartj/ehx393 Crossref PubMed Scopus (6658) Google Scholar , [2] Lawton J.S. Tamis-Holland J.E. Bangalore S. et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines. Circulation. 2022; 145: e18-e114https://doi.org/10.1161/CIR.0000000000001038 Crossref PubMed Scopus (340) Google Scholar ]. Multivessel coronary artery disease (MVD), defined by the presence of ≥50% stenosis in two or more major epicardial vessels, is present in approximately 50% of STEMI patients and these patients have and increased risk of ischemic events and worse prognosis, compared to those with one-vessel disease only [ 2 Lawton J.S. Tamis-Holland J.E. Bangalore S. et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines. Circulation. 2022; 145: e18-e114https://doi.org/10.1161/CIR.0000000000001038 Crossref PubMed Scopus (340) Google Scholar , 3 Sorajja P. Gersh B.J. Cox D.A. McLaughlin M.G. Zimetbaum P. Costantini C. et al. Impact of multivessel disease on reperfusion success and clinical outcomes in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction. Eur. Heart J. 2007; 28: 1709-1716https://doi.org/10.1093/eurheartj/ehm184 Crossref PubMed Scopus (383) Google Scholar , 4 Bates E.R. Tamis-Holland J.E. Bittl J.A. O’Gara P.T. Levine G.N. PCI strategies in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease. J. Am. Coll. Cardiol. 2016; 68: 1066-1081https://doi.org/10.1016/j.jacc.2016.05.086 Crossref PubMed Scopus (54) Google Scholar ]. The management of non-culprit lesions (NCLs) in STEMI has been the focus of intense research in the last decades therefore, the recommendations of the clinical practice guidelines have changed diametrically, from discouraged routine treatment [ [1] Ibanez B. James S. Agewall S. Antunes M.J. Bucciarelli-Ducci C. Bueno H. et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European society of cardiology (ESC). Eur. Heart J. 2018; 39: 119-177https://doi.org/10.1093/eurheartj/ehx393 Crossref PubMed Scopus (6658) Google Scholar , [5] O’Gara P.T. Kushner F.G. Ascheim D.D. et al. 2013 ACCF/AHA guideline for the management of STelevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. Circulation. 2013; 127: e362-e425https://doi.org/10.1161/CIR.0b013e3182742cf6 Crossref PubMed Scopus (2242) Google Scholar ] to recommending complete revascularization with the highest degree of recommendation (Class I, level of evidence A) in the most current [ [2] Lawton J.S. Tamis-Holland J.E. Bangalore S. et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines. Circulation. 2022; 145: e18-e114https://doi.org/10.1161/CIR.0000000000001038 Crossref PubMed Scopus (340) Google Scholar ]. However, there are still important gaps of evidence to decide the best complete revascularization strategy, such as the optimal timing, the tools for a better assessment of NCLs, and the management in specific subset such as cardiogenic shock or complex MVD [ [1] Ibanez B. James S. Agewall S. Antunes M.J. Bucciarelli-Ducci C. Bueno H. et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European society of cardiology (ESC). Eur. Heart J. 2018; 39: 119-177https://doi.org/10.1093/eurheartj/ehx393 Crossref PubMed Scopus (6658) Google Scholar , [2] Lawton J.S. Tamis-Holland J.E. Bangalore S. et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines. Circulation. 2022; 145: e18-e114https://doi.org/10.1161/CIR.0000000000001038 Crossref PubMed Scopus (340) Google Scholar , [6] Saito Y. Kobayashi Y. Percutaneous coronary intervention strategies in patients with acute myocardial infarction and multivessel disease: completeness, timing, lesion assessment, and patient status. J. Cardiol. 2019; 74: 95-101https://doi.org/10.1016/j.jjcc.2019.04.001 Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar ].