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Cardio Diabetes Medicine 2017 181

Non-Infarct Related Artery Intervention in

St-Elevation Myocardial Infarction With Multivessel Disease:
MultiVessel PCI in STEMI - Timing of Intervention?

Dr. Shirish Hiremath, MD. DM(Card). MNAMS. FISE

Director, Cath Lab Ruby Hall, President CSI 2016-2017
Managing Trustee & Chairman AIMS, Pune

Approach to Multivessel disease in STEMI: Perfect Is The Enemy of Good!
For patients presenting with ST-elevation myocardial infarction (STEMI), primary angioplasty (pPCI) of the cul-
prit vessel, is the treatment of choice [1, 2]. Recent advances in PCI techniques, hardware and antithrombotic
therapy alongwith reduced transportation time have led to significantly reduced mortality in pPCI. But 40-
60% patients with STEMI have multivessel disease (MVD) at the time of presentation. In STEMI, presence of
multivessel disease is associated with poor outcome compared to single vessel disease, including a need for
repeat revascularisation and repeat admissions with MI (fig.1). This increase in risk may be caused by function
of a noninfarct zone, extent of atherosclerotic burden, combination of stunned and hibernating myocardium,
or slow flow in a nonculprit vessel.

Fig 1: Mortality in STEMI depending on angiographic findings [3].
Optimum management of multivessel disease in STEMI is till subject of debate. In hemodynamically unstable
patients, multivessel PCI at the time of index procedure is the preferred approach, though not supported by
suffient data[1,2]. Different “non-culprit lesion” strategies in stable patients with STEMI and MVD undergo-
ing p-PCI have been compared in randomised studies and non-randomised observational registries, yielding
conflicting results. In this review article, we will discuss why guideline recommendations regarding multivessel
PCI in STEMI changed over last 5-7years and how to integrate it into daily clinical decision making.

Evidence- Pre2011:

Various small randomised and observational trials have suggested the benefit of multivessel PCI over culprit
only PCI in MVD-STEMI. Meta-analysis by Banglore et at have showed that for early outcomes, there was no
difference between groups for outcomes of mortality, MI, stroke, and target vessel revascularization, with a
44% decrease in repeat PCI and a 32% decrease in MACEs with multivessel revascularization. Similarly, for
long-term outcomes, there was no difference for outcomes of MI, target vessel revascularization, and stent
thrombosis, with a 33% decrease in mortality, a 43% decrease in repeat PCI, a 53% decrease in coronary artery

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