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Non-Infarct Related Artery Intervention in St-Elevation Myocardial Infarc-
186 tion With Multivessel Disease: MultiVessel PCI in STEMI:
Timing of Intervention?

observed that, there is no sufficient data to recommend the optimal timing of nonculprit vessel PCI and the
optimal method of evaluating nonculprit lesions (eg, percent diameter stenosis , fractional flow reserve)[15].

Fig.5: Change Class of Recommendation by AHA in accordance with the recent trials

Ongoing trials:
The largest trial addressing this very issue is the currently recruiting COMPLETE trial (NCT01740479), which will
randomize 3900 STEMI patients with multi-vessel disease in North America and Europe to culprit-lesion-only
or staged complete revascularization.
The COMPARE-ACUTE trial (NCT01399736) is based on FFR measurements in the non-culprit vessels, but
aims at single procedure multi-vessel revascularization.
Finally, the CROSS-AMI trial (NCT01179126) was designed to compare stress echo-guided revascularization
vs. an angiography-based strategy.

Clinical perspective:
MVD-STEMI is a very heterogeneous population , so no common strategy will be applicable to this subset
and any revascularisation strategy should be individualised. Interventionalist should focus first on the best
possible p-PCI result on the culprit lesion which brought the patient to the cathlab i.e to achieve TIMI III flow
with good ST-resolution achieved. A complicated p-PCI with long procedural time, significant contrast load
and a suboptimal result, including “slow or no-reflow” and/ or distal embolisation, would definitively argue
against additional non-culprit PCI in a stable patient during the index procedure. Anatomical complexity of the
non-culprit disease, assessed by SYNTAX score, and left ventricular/valve function, a complete risk profile,
including age and comorbidities, has to be integrated into the decision-making process to select the best
revascularisation strategy which is best decided by ‘Heart Team approach’. Complete revascularisation can
be considered hemodynamically

stable patients with persisting chest pain or significant residual ST-segment elevation. As most of patients
with STEMI were asymptomatic prior to the event, nonculprit lesion should be considered as stable CAD and
unless this is evidence of ischeamia (FFR), such lesion should not be intervened. In a patient with complex
multivessel disease, impaired left ventricular function and diabetes, surgical revascularisation could be con-
sidered despite STEMI as the index event.
Complete revascularization should not be routinely performed ad-hoc, but based on individual and careful
patient and lesion assessments. The best timing of the staged PCI (during the index admission or within
weeks) and the question of stratification for evidence of ischaemia remain to be answered in upcoming trials.

GCDC 2017