Did we pass the border? Routine multivessel intervention in STEMI patients

The issue of multivessel percutaneous revascularization in ST-segment elevation myocardial infarction (STEMI) is currently unambiguously decided by the guidelines: with the exception of cardiogenic shock, percutaneous coronary intervention (PCI) should be limited to the culprit stenosis in the infarct-related artery (IRA), with the class and level of evidence IIaB in the ESC and IIIB in ACCF/ /AHA/SCAI guidelines [1, 2]. It is because there is strong evidence from few clinical randomized trials and much more registries that PCI of a non-infarct artery at the time of primary PCI in stable patients is associated with worse clinical outcomes [3–7]. In contrary, in STEMI patients with cardiogenic shock and multivessel disease, revascularization of the IRA and non-infarct arteries may be necessary to maximize myocardial perfusion, allow myocardial recovery and improve survival [2]. The results of the study published by Lee et al. [8] in this issue of “Cardiology Journal” support above findings. However, authors also suggested that multivessel revascularization might be equally safe and beneficial compared with IRA-only intervention, especially done by experienced interventional cardiologist and in the case of multiple culprit lesion is suspected. The last part of this sentence is not clearly supported by this study but intuitively true. Much more interesting is that primary study end-point, 12-month major adverse cardiac events, was equally frequent between IRA-only revascularization and multivessel revascularization. This study finding needs to be commented, because it potentially opens the door for routine non-IRA revascularization in stable patients with STEMI and multivessel coronary artery disease. First, as authors admitted, their study was a non-randomized registry with unavoidable selection bias. In IRA-only revascularization cohort patients were with more comorbidities and poorer angiographic result (less TIMI-3 flow after IRA PCI). This could possibly refrain the operators to further consider nonIRA intervention. Secondly, there was no clearly defined if in cohort of patients who underwent multivessel revascularization in the settings of STEMI non-IRA PCI was performed during primary intervention or at a latter course of index hospitalization or even at the next hospitalization. This is maybe a crucial issue, because there is evidence that stable patients with STEMI and multivessel coronary artery may benefit substantially from staged revascularization [9–11]. Taking into consideration these limitations, part of them resulting from non-randomized study design, registry results should be interpreted with a great caution and as a hypothesis generating for future randomized trials. It seems mandatory before multivessel PCI would be recommended in the settings of stable STEMI patients that FAME-like designed trial with fractional flow reserve guided intervention for stenoses located in non-IRAs but after optimal PCI result in IRA should be adequately designed and executed.