Multivessel vs. culprit-lesion only percutaneous coronary intervention in ST-elevation myocardial infarction
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Hans-Josef Feistritzer · Alexander Jobs · Steffen Desch · Holger Thiele Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
Multivessel vs. culprit-lesion only percutaneous coronary intervention in ST-elevation myocardial infarction Early revascularization of the culprit lesion is essential to decrease myocardial damage and preserve myocardial function in patients with ST-elevation myocardial infarction (STEMI). Primary percutaneous coronary intervention (PCI) has been established as the preferred reperfusion strategy in STEMI patients presenting within recommended timeframes [1–8]. Multivessel coronary artery disease is present in approximately 50% of STEMI patients. These patients are more likely to have absent ST-segment recovery and show lower left ventricular (LV) ejection fraction and higher mortality compared with those who have single-vessel disease [9–11]. The optimal treatment of noninfarct-related coronary arteries (nonIRA) has been a subject of debate for many years. While earlier observational studies suggested worse outcomes with immediate multivessel PCI, several subsequent randomized controlled trials (RCTs) showed favorable results with multivessel revascularization (. Fig. 1; [12–19]). However, these beneficial findings were substantially driven by a reduction of subsequent revascularizations or by new angina symptoms in the multivessel PCI group in many of these trials. Recently, the largest trial in the field by far—the COMPLETE (The Complete versus Culprit-Only Revascularization Strategies to Treat Multivessel Disease after Early PCI for STEMI) trial—showed a significant reduction in the combined endpoint of cardiovascular mortality and myocardial reinfarction
[20]. Hence, a reduction in hard clinical events with multivessel PCI compared with culprit vessel-only PCI in STEMI was demonstrated for the first time in an adequately powered trial. The present review summarizes the current evidence for multivessel versus culprit vessel-only PCI in STEMI patients. Importantly, we focus on STEMI patients with stable hemodynamics. However, revascularization strategies in acute myocardial infarction complicated by cardiogenic shock (CS) are briefly addressed in a separate section.
Data from observational studies In the 2012 European guidelines on the management of STEMI patients, immediate PCI of non-infarct-related coronary arteries was not recommended [21]. This recommendation was based on data derived from observational studies [12–15]. In these trials, multivessel PCI was performed either immediately during the initial procedure or as a staged procedure. While higher rates of reinfarction were reported in patients undergoing multivessel PCI [12, 15], data regarding mortality were inconsistent. Hannan et al. reported higher inhospital mortality with immediate multivessel revascularization compared with culprit vessel-only PCI [14]. By contrast, other studies did not show any significant difference regarding in-hospital, 30day, and long-term mortality [12
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