How to treat patients with ST-elevation acute myocardial infarction and multi-vessel disease?

Area of Science:

• Cardiology
• Interventional Cardiology
• Acute Coronary Syndromes

Background:

• Over 50% of ST-segment elevation myocardial infarction (STEMI) patients present with multi-vessel coronary artery disease (CAD).
• Multi-vessel CAD in STEMI is associated with a worse prognosis compared to single-vessel disease.
• Current treatment strategies for STEMI with multi-vessel CAD are diverse, including acute multi-vessel PCI, staged PCI, and conservative management with primary PCI of the infarct-related artery (IRA).

Purpose of the Study:

• To review international experiences and expert opinions on the optimal management of STEMI patients with multi-vessel CAD.
• To provide guidance on individualized treatment approaches for this patient population.
• To propose general rules for managing non-infarct-related lesions in STEMI patients pending large randomized trials.

Main Methods:

• This is a review paper synthesizing existing international data and expert consensus.
• The authors present their opinion based on current clinical practice and evidence.
• The review focuses on comparing different revascularization strategies for multi-vessel CAD in the context of STEMI.

Main Results:

• Single-vessel acute PCI targeting only the IRA is proposed as the default strategy during the acute phase of STEMI.
• Acute multi-vessel PCI is considered justifiable only in select cases with multiple critical (>90%) and potentially unstable non-IRA lesions.
• Significant non-IRA lesions can be managed either with optimal medical therapy or through staged revascularization procedures, with both approaches deemed acceptable.

Conclusions:

• Treatment for STEMI patients with multi-vessel CAD should be individualized.
• Acute single-vessel PCI of the IRA is the recommended default approach.
• Staged PCI or medical management are acceptable strategies for non-infarct-related significant lesions.