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Revascularization Strategies in STEMI with Multivessel Disease: Deciding on Culprit Versus Complete-Ad Hoc or Staged
Shalin Patel1, Steven R Bailey2
1From the Janey Briscoe Center of Excellence for Cardiovascular Research, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78232, USA.
Insights
Complete revascularization in ST-segment elevation myocardial infarction (STEMI) with multivessel disease is debated. This review examines which patients benefit most from complete revascularization and optimal timing.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- ST-segment elevation myocardial infarction (STEMI) patients frequently have multivessel disease, a significant risk factor for mortality.
- Multivessel disease in STEMI increases short- and long-term morbidity and mortality.
- Complete revascularization may offer benefits like reduced mortality and resource utilization.
Purpose of the Study:
- To address the clinical dilemma of complete revascularization in STEMI patients with multivessel disease.
- To review the evidence for clinical benefit from revascularizing non-culprit lesions during STEMI.
- To discuss the optimal timing for multivessel revascularization in the peri-infarct period.
Main Methods:
- Review of current literature and clinical guidelines.
- Analysis of patient populations and outcomes related to multivessel PCI in STEMI.
- Evaluation of factors influencing the decision for complete revascularization.
Main Results:
- Up to 50% of STEMI patients present with multivessel disease.
- The optimal strategy and timing for revascularizing non-culprit lesions remain controversial.
- Patient comorbidities, myocardial risk, lesion complexity, and ventricular function are key considerations.
Conclusions:
- The decision for complete revascularization in STEMI requires careful consideration of individual patient factors.
- Further research is needed to define optimal revascularization strategies and timing in STEMI with multivessel disease.
- Personalized approaches are essential to maximize benefits and minimize risks.
Purpose Of Review:
This review will address the clinical conundrum of those who may derive clinical benefit from complete revascularization of coronary stenosis that are discovered at the time of ST segment elevation myocardial infarction (STEMI). The decision to revascularize additional vessels with angiographic stenosis beyond the culprit lesion remains controversial, as does the timing of revascularization.
Recent Findings:
STEMI patients represent a high-risk patient population that have up to a 50% prevalence of multivessel disease. Multivessel disease represents an important risk factor for short- and long-term morbidity and mortality. Potential benefits of multivessel PCI for STEMI might include reduced short- and long-term mortality, revascularization, reduced resource utilization, and costs. Which population will benefit and what the optimal timing of revascularization in the peri-MI period remains controversial. Consideration of multivessel revascularization in the setting of STEMI may occur in up to one half of STEMI patients. Evaluation of the comorbidities including diabetes, extent of myocardium at risk, lesion complexity, ventricular function, and risk factors for complications such as contrast induced nephropathy which is important in determining the appropriate care pathway.
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