Multivessel Revascularization and ST-Segment–Elevation Myocardial Infarction
Do We Have the Complete Answer?
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- fractional flow reserve
- multivessel percutaneous coronary intervention
- percutaneous coronary intervention
- ST-segment–elevation myocardial infarction
A large number of observational studies and a few randomized controlled trials (RCTs) among patients with ST-segment–elevation myocardial infarction (STEMI) and multivessel disease have compared strategies of complete revascularization (CR) (either acutely or as a staged procedure) and culprit lesion only revascularization.1–3 Two small RCTs4,5 have recently reported significant reductions in composite ischemic outcomes with immediate percutaneous coronary intervention (PCI) of nonculprit lesions versus culprit lesion only PCI. A third, larger RCT6 employing staged fractional flow reserve (FFR)-based PCI of the nonculprit lesions reported similar findings. These trials had composite outcomes that included revascularization and recurrent angina, which can be influenced by knowledge of the initial treatment allocation given the open-label designs and were not powered for the hard end points of death or recurrent myocardial infarction (MI). Despite these limitations, many now believe complete revascularization at the time of the index catheterization is both efficacious and safe. The 2015 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions focused update on STEMI recently changed nonculprit vessel revascularization at the time of STEMI from a Class III (Level of Evidence B) recommendation to a Class IIB (Level of Evidence B) recommendation.7 As 30% to 40% of patients presenting with STEMI have multivessel disease, the implications for global cardiovascular care are substantial. One question remains: do we really have the complete answer?
See Article by Lønborg et al
The DANAMI-3-PRIMULTI study (Primary PCI in Patients With ST-Elevation Myocardial Infarction and Multivessel Disease: Treatment of Culprit Lesion Only or Complete Revascularization)6 randomized 314 patients to CR guided by FFR values obtained at repeat angiography 2 days post STEMI and 313 patients to no further invasive management after their index angiography. The primary end point was a composite of all-cause mortality, nonfatal …