THE COMPLICATED STEMI: WHAT TO DO WITH MULTIVESSEL DISEASE


Gregory W. Barsness, M.D., Mayo Clinic, Rochester, MN, USA

Primary PCI is the treatment of choice for the majority of patients presenting with myocardial infarction. In many instances, the choice of revascularization strategy is complicated by the presence of multivessel disease, especially in the presence of additional comorbidities, chronic total occlusions and, infrequently, hemodynamic or electrical instability. Although currently discouraged by guideline statements and expert consensus, a strategy of immediate full revascularization is sometimes considered as a means of improving prognosis in patients with multiple potential infarct arteries and an inconclusive ECG or shock, or even as a means of enhancing the patient’s experience or in an effort at cost containment. Alternatively, a strategy of culprit-only PCI may be favored in an effort to reduce potential harm, reduce contrast and radiation exposure or even to provide the opportunity to further gauge patient baseline and socioeconomic characteristics to better tailor additional therapies. This discussion will focus on available data to support an initial strategy of culprit-only intervention, followed by individualization of revascularization and medical therapy over the ensuing weeks.