Current recommendations for revascularization of non-infarct-related artery in patients presenting with ST-segment elevation myocardial infarction and multivessel disease

Abstract

ST-segment elevation myocardial infarction (STEMI) is a leading cause of morbidity and mortality worldwide. Immediate reperfusion therapy of the infarct-related artery (IRA) is the mainstay of treatment, either via primary percutaneous coronary intervention (PPCI) or thrombolytic therapy when PPCI is not feasible. Several studies have reported the incidence of multivessel disease (MVD) to be about 50% of total STEMI cases. This means that after successful PPCI of the IRA, residual lesion(s) of the non-IRA may persist. Unlike the atherosclerotic plaque of stable coronary artery disease, the residual obstructive lesion of the non-IRA contains a significantly higher prevalence of vulnerable plaques. Since these lesions are a strong predictor of acute coronary syndrome, if left untreated they are a possible cause of future adverse cardiovascular events. Percutaneous coronary intervention (PCI) of the obstructive lesion of the non-IRA to achieve complete revascularization (CR) is therefore preferable. Several major randomized controlled trials (RCTs) and meta-analyses demonstrated the clinical benefits of the CR strategy in the setting of STEMI with MVD, not only for enhancing survival but also for reducing unplanned revascularization. The CR strategy is now supported by recently published clinical practice guidelines. Nevertheless, the benefit of revascularization must be weighed against the risks from additional procedures.

Keywords: ST-segment elevation myocardial infarction; complete revascularization; infarct-related artery; multivessel disease; percutaneous coronary intervention.

Figure 1

The summary of timing for complete revascularization and the method of guidance for PCI. COMPARE-ACUTE, Comparison Between FFR Guided Revascularization vs. Conventional Strategy in Acute STEMI Patients With MVD; COMPLETE, Complete vs. Culprit-Only Revascularization Strategies to Treat Multivessel Disease after Early PCI for STEMI; CULPRIT-SHOCK, Culprit Lesion Only PCI vs. Multivessel PCI in Cardiogenic Shock; CVLPRIT, Complete vs. Lesion-only Primary PCI; DANAMI3-PRIMULTI, Primary PCI in Patients With ST-elevation Myocardial Infarction and Multivessel Disease: Treatment of Culprit Lesion Only or Complete Revascularization; FFR, fractional flow reserve; FLOWER-MI, FLOW Evaluation to Guide Revascularization in Multi-vessel ST-elevation Myocardial Infarction IRA, infarct-related artery; PCI, percutaneous coronary intervention; PRAMI, Preventive Angioplasty in Acute Myocardial Infarction.

Figure 2

The practical approach for complete revascularization in patients with STEMI and MVD. CABG, coronary artery bypass graft; CS, cardiogenic shock; FFR; fractional flow reserve; IRA, infarct-related artery; MVD, multivessel disease; PCI, percutaneous coronary intervention; STEMI, ST-segment elevation myocardial infarction.