How to treat patients with ST-elevation acute myocardial infarction and multi-vessel disease?

Petr Widimsky, David R Holmes Jr, Petr Widimsky, David R Holmes Jr

Abstract

Over 50% of ST-segment elevation myocardial infarction (STEMI) patients suffer multi-vessel coronary artery disease, which is known to be associated with worse prognosis. Treatment strategies used in clinical practice vary from acute multi-vessel percutaneous coronary intervention (PCI), through staged PCI procedures to a conservative approach with primary PCI of only the infarct-related artery (IRA) and subsequent medical therapy unless recurrent ischaemia occurs. Each approach has advantages and disadvantages. This review paper summarizes the international experience and authors' opinion on this clinically important question. Multi-vessel disease in STEMI is not a single entity and thus the treatment approach should be individualized. However, the following general rules can be proposed till future large randomized trials prove otherwise: (i) Single-vessel acute PCI should be the default strategy (to treat only the IRA during the acute phase of STEMI). (ii) Acute multi-vessel PCI can be justified only in exceptional patients with multiple critical (>90%) and potentially unstable lesions. (iii) Significant lesions of the non-infarct arteries should be treated either medically or by staged revascularization procedures-both options are currently acceptable.

Figures

Figure 1
Figure 1
The relative proportion of single- vs. multi-vessel disease and of the three most frequently used PCI (percutaneous coronary intervention) strategies for multi-vessel disease (adopted from Corpus et al.).
Figure 2
Figure 2
In-hospital mortality after multi-vessel vs. single-vessel percutaneous coronary intervention in STEMI (ST-elevation myocardial infarction) from the US National Cardiovascular Data Registry (adopted from Chen et al.).
Figure 3
Figure 3
The SWISSI II randomized trial. Kaplan–Meier survivor function for cardiac death, non-fatal myocardial infarction, and symptom-driven revascularization. From Erne et al. Permission for publication granted.

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