Complete Revascularisation in ST-elevation MI: Do We Really Buy It? Challenging the Current Approach to Bystander Percutaneous Coronary Intervention

Complete revascularisation during ST-elevation MI (STEMI) has Class 1A guideline support based on multiple randomised controlled trials showing improved clinical outcomes compared with culprit-only percutaneous coronary intervention. However, the concept that all STEMI patients with bystander disease should undergo complete revascularisation is flawed. The randomised controlled trials have highly variable anatomical and physiological inclusion criteria and drivers for outcome benefit, to the extent that it is hard to pick out a possible mechanism of effect. There is a case to pursue some fundamental questions about how prophylactic stenting may help bystander disease in STEMI patients, as well as to try to establish whether there are high-risk patients/vessels/lesions that derive substantial benefit from stenting and, conversely, others in whom it is futile.