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4.1 COMPLETE Revascularization Following STEMI: Not Whether, When
These proceedings summarize the educational activity of the 17th Biennial Meeting of the International Andreas Gruentzig Society held January 30 to February 2, 2024 in Chiang Rai, Thailand.
Faculty Disclosures Vendor Acknowledgments
Statement of the problem or issue
Eight years ago, we did not perform multivessel intervention in ST-elevation myocardial infarction (STEMI), it was a Class III recommendation, that is, don't do it. We even had the CULPRIT-Shock trial, saying, just treat the culprit lesion. Now, after five or more additional trials, complete multivessel revascularization is a Class Ia recommendation. This is important, since 50% of patients with STEMI have multivessel disease present. But, we're not just leaving it at STEMI anymore. Now it's all the acute coronary syndromes (ACS) together; it’s STEMI and non-STEMI (NSTEMI), too. The only caveat with NSTEMI is you have to make sure you know which is the culprit lesion.
Gaps in current knowledge
The largest gap we have is the question of how to determine the approach, how to choose the strategy, for the treatment of the non-culprit lesion or lesions. Which ones should be treated and when should they be treated? Is it based on angiographic severity of stenosis? Is it based on the territory at risk? For intermediate lesions, is it based on FFR or iFR or IVUS? How are comorbidities like age and frailty factored into the decision? What if additional therapies will be required, like ablative treatment for a calcified lesion, how does that fit in? And if we decide to delay treatment for non-culprit lesions at the primary procedure, when should we come back and perform them? The next day? During the same hospital admission? After discharge at a later date? What are the criteria by which we should decide these questions?
Possible solutions and future directions
Clinical trials are underway that will provide additional insights into these issues.1-6
References
- IVUS Versus FFR for Non-infarct Related Artery Lesions in Patients With Multivessel Disease and Acute STEMI (FRAME-AMI2). NCT05812963.
- Fractional Flow Reserve Guided Immediate Versus Staged Complete Myocardial Revascularization in Patients With ST-segment Elevation Myocardial Infarction With Multivessel Disease. NCT05967663.
- Deferred Stenting in Patients With Anterior Wall STEMI. NCT03744000.
- Predicting the Risk of Non-culprit Coronary Artery Disease After a Heart Attack (OCT-RISK). NCT05781087.
- STaged Interventional Strategies for Acute ST-seGment Elevation Myocardial Infarction Patient With Multi-vessel Disease (STAGED). NCT04918030.
- Post-Revascularization Optimization and PHysiological Evaluation of intermediaTe Lesions (PROPHET-FFR). NCT05056662.
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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of the Journal of Invasive Cardiology or HMP Global, their employees, and affiliates.
