Complete Revascularisation in ST-elevation MI: Do We Really Buy It? Challenging the Current Approach to Bystander...

Area of Science:

• Cardiology
• Interventional Cardiology
• Clinical Trials

Background:

• Complete revascularisation in ST-elevation myocardial infarction (STEMI) is guideline-supported (Class 1A) due to improved outcomes over culprit-only percutaneous coronary intervention.
• However, the universal application of complete revascularisation in STEMI patients with bystander lesions is debated.
• Existing randomized controlled trials exhibit significant variability in anatomical and physiological inclusion criteria, complicating the identification of specific benefit drivers.

Purpose of the Study:

• To critically evaluate the established concept of complete revascularisation in STEMI patients with bystander disease.
• To investigate the potential mechanisms through which prophylactic stenting might benefit bystander lesions in STEMI.
• To identify specific patient, vessel, or lesion characteristics that predict substantial benefit versus futility from prophylactic stenting.

Main Methods:

• Review and analysis of existing randomized controlled trials comparing complete revascularisation with culprit-only percutaneous coronary intervention in STEMI.
• Exploration of anatomical and physiological data from trials to identify potential outcome benefit drivers.
• Formulation of research questions to guide future investigations into selective prophylactic stenting.

Main Results:

• While complete revascularisation shows improved outcomes, the heterogeneity of trial data makes it difficult to pinpoint the exact mechanism of benefit.
• The benefit of prophylactic stenting in bystander lesions is not universally applicable across all STEMI patients.
• Significant variability exists in patient selection, lesion characteristics, and physiological assessments within current trial data.

Conclusions:

• The assumption that all STEMI patients with bystander disease require complete revascularisation is potentially flawed.
• Further fundamental research is warranted to understand the role and optimal selection criteria for prophylactic stenting in STEMI.
• Future studies should aim to stratify STEMI patients to identify those who would maximally benefit from, and those for whom prophylactic stenting would be futile.