Skip to main content
SpringerLink
Log in

Complete Revascularization in Patients With STEMI and Multivessel Coronary Artery Disease: Is It Beneficial?

  • Coronary Artery Disease (D Feldman and V Voudris, Section Editors)
  • Published:
Current Treatment Options in Cardiovascular Medicine Aims and scope Submit manuscript

Abstract

Purpose of review

Multivessel coronary artery disease is usually present in up to 50% of patients presenting with ST-elevation myocardial infarction (STEMI). The optimal revascularization approach for non-infarct related lesions has been a topic of recent debate. Various observational studies and clinical trials have been conducted to assess the impact of multivessel revascularization. In this review, we aim to present the currently available evidence behind the different revascularization strategies.

Recent findings

Early observational studies, registry-based analyses, and meta-analyses had suggested a benefit of culprit only revascularization over complete revascularization. However, in several recent randomized clinical trials, a complete revascularization approach for non-infarct-related lesions, either during the index hospitalization or as a staged approach, has been associated with improved outcomes. These findings exclude patients with cardiogenic shock and chronic total occlusions.

Summary

Clinical decisions regarding the extent and timing of revascularization in STEMI patients necessitate an individualized, patient-oriented approach. Based on the evidence from recent clinical trials, complete revascularization of non-culprit lesions in STEMI should be considered.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: •• Of major importance

  1. McManus DD, Gore J, Yarzebski J, Spencer F, Lessard D, Goldberg RJ. Recent trends in the incidence, treatment, and outcomes of patients with STEMI and NSTEMI. Am J Med. 2011;124:40–7.

    Article  Google Scholar 

  2. Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke statistics-2019 update: a report from the American Heart Association. Circulation. 2019;139:e56–e528.

    Article  Google Scholar 

  3. •• Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv. 2016;87:1001–19. 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction.

    Article  Google Scholar 

  4. •• Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39:119–77. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST segment elevation.

    Article  Google Scholar 

  5. Tamis-Holland JE, O’Gara P. Highlights from the 2013 ACCF/AHA guidelines for the management of ST-elevation myocardial infarction and beyond. Clin Cardiol. 2014;37:252–9.

    Article  Google Scholar 

  6. Cavender MA, Milford-Beland S, Roe MT, Peterson ED, Weintraub WS, Rao SV. Prevalence, predictors, and in-hospital outcomes of non-infarct artery intervention during primary percutaneous coronary intervention for ST segment elevation myocardial infarction (from the National Cardiovascular Data Registry). Am J Cardiol. 2009;104:507–13.

    Article  Google Scholar 

  7. Iqbal MB, Ilsley C, Kabir T, Smith R, Lane R, Mason M, et al. Culprit vessel versus multivessel intervention at the time of primary percutaneous coronary intervention in patients with ST segment-elevation myocardial infarction and multivessel disease: real-world analysis of 3984 patients in London. Circ Cardiovasc Qual Outcomes. 2014;7:936–43.

    Article  Google Scholar 

  8. Lu C, Huang H, Li J, Zhao J, Zhang Q, Zeng Z, et al. Complete versus culprit-only revascularization during primary percutaneous coronary intervention in ST-elevation myocardial infarction patients with multivessel disease: a meta-analysis. Kaohsiung J Med Sci. 2013;29:140–9.

    Article  Google Scholar 

  9. Iqbal MB, Nadra IJ, Ding L, Fung A, Aymong E, Chan AW, et al. Culprit vessel versus multivessel versus in-hospital staged intervention for patients with ST segment elevation myyocardial infarction and multivessel disease: stratified analyses in high-risk patient groups and anatomic subsets of nonculprit disease. JACC Cardiovasc Interv. 2017;10:11–23.

    Article  Google Scholar 

  10. Manari A, Varani E, Guastaroba P, Menozzi M, Valgimigli M, Menozzi A, et al. Long-term outcome in patients with ST segment elevation myocardial infarction and multivessel disease treated with culprit-only, immediate, or staged multivessel percutaneous revascularization strategies: insights from the REAL registry. Catheter Cardiovasc Interv. 2014;84:912–22.

    Article  Google Scholar 

  11. Barringhaus KG, Park KL, McManus DD, Steg PG, Montalescot G, Van de Werf F, et al. Outcomes from patients with multi-vessel disease following primary PCI: staged PCI imparts very low mortality. Catheter Cardiovasc Interv. 2011;77:617–22.

  12. Toyota T, Shiomi H, Taniguchi T, Morimoto T, Furukawa Y, Nakagawa Y, et al. Culprit vessel-only vs. staged multivessel percutaneous coronary intervention strategies in patients with multivessel coronary artery disease undergoing primary percutaneous coronary intervention for ST segment elevation myocardial infarction. Circ J. 2016;80:371–8.

  13. Jang JS, Spertus JA, Arnold SV, Shafiq A, Grodzinsky A, Fendler TJ, et al. Impact of multivessel revascularization on health status outcomes in patients with ST segment elevation myocardial infarction and multivessel coronary artery disease. J Am Coll Cardiol. 2015;66:2104–13.

  14. Marino M, Crimi G, Leonardi S, Ferlini M, Repetto A, Camporotondo R, et al. Comparison of outcomes of staged complete revascularization versus culprit lesion-only revascularization for ST-elevation myocardial infarction and multivessel coronary artery disease. Am J Cardiol. 2017;119:508–14.

  15. Vlaar PJ, Mahmoud KD, Holmes DR Jr, van Valkenhoef G, Hillege HL, van der Horst IC, et al. Culprit vessel only versus multivessel and staged percutaneous coronary intervention for multivessel disease in patients presenting with ST segment elevation myocardial infarction: a pairwise and network meta-analysis. J Am Coll Cardiol. 2011;58:692–703.

  16. Bainey KR, Mehta SR, Lai T, Welsh RC. Complete vs culprit-only revascularization for patients with multivessel disease undergoing primary percutaneous coronary intervention for ST segment elevation myocardial infarction: a systematic review and meta-analysis. Am Heart J. 2014;167:1–14.e2.

  17. O’Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:e362–425.

  18. Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, et al. 2014 ESC/EACTS guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2014;35:2541–619.

  19. •• Wald DS, Morris JK, Wald NJ, Chase AJ, Edwards RJ, Hughes LO, et al. Randomized trial of preventive angioplasty in myocardial infarction. N Engl J Med. 2013;369:1115–23. PRAMI trial – first clinical trial to show improved primary outcome in the complete revascularization group.

  20. •• Gershlick AH, Khan JN, Kelly DJ, Greenwood JP, Sasikaran T, Curzen N, et al. Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel disease: the CvLPRIT trial. J Am Coll Cardiol. 2015;65:963–72. CvLPRIT trial – confirmed the PRAMI trial findings. Improved outcomes were the result of a reduction in ischemia driven or urgent revascularization.

  21. Gershlick AH, Banning AS, Parker E, Wang D, Budgeon CA, Kelly DJ, et al. Long-term follow-up of complete versus lesion-only revascularization in STEMI and multivessel disease: the CvLPRIT trial. J Am Coll Cardiol. 2019;74:3083–94.

  22. Ntalianis A, Sels JW, Davidavicius G, Tanaka N, Muller O, Trana C, et al. Fractional flow reserve for the assessment of nonculprit coronary artery stenoses in patients with acute myocardial infarction. JACC Cardiovasc Interv. 2010;3:1274–81.

  23. •• Engstrøm T, Kelbæk H, Helqvist S, Høfsten DE, Kløvgaard L, Holmvang L, et al. Complete revascularisation versus treatment of the culprit lesion only in patients with ST segment elevation myocardial infarction and multivessel disease (DANAMI-3—PRIMULTI): an open-label, randomised controlled trial. Lancet. 2015;386:665–71. DANAMI-3-PRIMULTI trial– included the use of Factional Flow Reserve (FFR) to evaluate non-culprit lesion severity and guide revascularization.

  24. •• Smits PC, Abdel-Wahab M, Neumann FJ, Boxma-de Klerk BM, Lunde K, Schotborgh CE, et al. Fractional flow reserve-guided multivessel angioplasty in myocardial infarction. N Engl J Med. 2017;376:1234–44. COMPARE-ACUTE trial - FFR procedure was performed during primary PCI in both groups in order to limit the need for sequential catheterizations and limit costs.

  25. •• Mehta SR, Wood DA, Storey RF, Mehran R, Bainey KR, Nguyen H, et al. Complete revascularization with multivessel PCI for myocardial infarction. N Engl J Med. 2019;381:1411–21. COMPLETE trial - largest trial, adequately powered to assess whether CR strategy would lead to a meaningful reduction in the risk of cardiovascular death or new MI. Decreased primary outcome driven by a decrease in new MI.

    Article  Google Scholar 

  26. Thiele H, Akin I, Sandri M, Fuernau G, de Waha S, Meyer-Saraei R, et al. PCI strategies in patients with acute myocardial infarction and cardiogenic shock. N Engl J Med. 2017;377:2419–32.

    Article  Google Scholar 

  27. •• Claessen BE, Dangas GD, Weisz G, Witzenbichler B, Guagliumi G, Möckel M, et al. Prognostic impact of a chronic total occlusion in a non-infarct-related artery in patients with ST segment elevation myocardial infarction: 3-year results from the HORIZONS-AMI trial. Eur Heart J. 2012;33:768–75. EXPLORE trial – Worse outcomes with complete revascularization in CTO patients.

    Article  Google Scholar 

  28. Pinilla-Echeverri N, Mehta SR, Wang J, Lavi S, Schampaert E, Cantor WJ, et al. Nonculprit lesion plaque morphology in patients with ST segment-elevation myocardial infarction: results from the COMPLETE trial optical coherence tomography substudys. Circ Cardiovasc Interv. 2020;13:e008768.

    Article  CAS  Google Scholar 

  29. Ahmad Y, Howard JP, Arnold A, Prasad M, Seligman H, Cook CM, et al. Complete revascularization by percutaneous coronary intervention for patients with ST segment-elevation myocardial infarction and multivessel coronary artery disease: an updated meta-analysis of randomized trials. J Am Heart Assoc. 2020;9:e015263.

    Article  Google Scholar 

  30. Reyentovich A, Barghash MH, Hochman JS. Management of refractory cardiogenic shock. Nat Rev Cardiol. 2016;13:481–92.

    Article  Google Scholar 

  31. Thiele H, Desch S, Piek JJ, Stepinska J, Oldroyd K, Serpytis P, et al. Multivessel versus culprit lesion only percutaneous revascularization plus potential staged revascularization in patients with acute myocardial infarction complicated by cardiogenic shock: design and rationale of CULPRIT-SHOCK trial. Am Heart J. 2016;172:160–9.

    Article  Google Scholar 

  32. Webb JG, Lowe AM, Sanborn TA, White HD, Sleeper LA, Carere RG, et al. Percutaneous coronary intervention for cardiogenic shock in the SHOCK trial. J Am Coll Cardiol. 2003;42:1380–6.

    Article  Google Scholar 

  33. Hochman JS, Sleeper LA, Webb JG, Dzavik V, Buller CE, Aylward P, et al. Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction. Jama. 2006;295:2511–5.

    Article  Google Scholar 

  34. Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2011;124:e574–651.

    PubMed  Google Scholar 

  35. Steg PG, James SK, Atar D, Badano LP, Blömstrom-Lundqvist C, Borger MA, et al. ESC guidelines for the management of acute myocardial infarction in patients presenting with ST segment elevation. Eur Heart J. 2012;33:2569–619.

    Article  CAS  Google Scholar 

  36. •• Mylotte D, Morice MC, Eltchaninoff H, Garot J, Louvard Y, Lefèvre T, et al. Primary percutaneous coronary intervention in patients with acute myocardial infarction, resuscitated cardiac arrest, and cardiogenic shock: the role of primary multivessel revascularization. JACC Cardiovasc Interv. 2013;6:115–25. CULPRIT-SHOCK trial – Complete revascularization in shock patients associated with worse outcomes.

    Article  Google Scholar 

  37. Henriques JP, Hoebers LP, Råmunddal T, Laanmets P, Eriksen E, Bax M, et al. Percutaneous intervention for concurrent chronic total occlusions in patients with STEMI: the EXPLORE trial. J Am Coll Cardiol. 2016;68:1622–32.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Cardiology, Department of Medicine, Rush University Medical Center, 1717 W. Congress Parkway, Suite 321 Kellogg, Chicago, IL, 60612, USA

    Konstantinos V. Voudris MD, PhD

  2. Division of Cardiology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA

    Dmitriy N. Feldman MD

Authors
  1. Konstantinos V. Voudris MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Dmitriy N. Feldman MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Konstantinos V. Voudris MD, PhD.

Ethics declarations

Conflict of interest

Konstantinos V. Voudris declares that he has no conflict of interest. Dmitriy N. Feldman declares that he has no conflict of interest.

Human and animal rights and informed consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Coronary Artery Disease

Rights and permissions

Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Voudris, K.V., Feldman, D.N. Complete Revascularization in Patients With STEMI and Multivessel Coronary Artery Disease: Is It Beneficial?. Curr Treat Options Cardio Med 23, 15 (2021). https://doi.org/10.1007/s11936-020-00887-x

Download citation

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s11936-020-00887-x

Keywords

Search

Navigation