2026 Focus Update of the 2021 Korean Society of Myocardial Infarction Expert Consensus Document on Revascularization for Acute Coronary Syndromes

This focused update from the Korean Society of Myocardial Infarction provides consensus recommendations for revascularization in acute coronary syndrome (ACS), integrating major trial evidence since 2021 with Korean real-world practice. A multidisciplinary writing committee reviewed randomized trials, meta-analyses, and recent guidelines, and achieved consensus document. Key recommendations are as follows: 1) Cardiogenic shock: prioritize culprit-first revascularization with early reassessment; apply mechanical circulatory support selectively, guided by shock phenotype and escalation criteria rather than routine use; 2) Non-ST segment elevation ACS: use risk-stratified invasive timing with clear triggers for urgent versus early angiography; 3) Access and imaging: adopt radial-first access and broaden intravascular imaging for complex anatomy, ambiguous culprit lesions, and optimization of stent expansion; 4) Non-culprit lesion: favor complete revascularization in ST-segment elevation myocardial infarction (MI) with multivessel disease; select immediate versus staged procedures based on hemodynamics, ischemic burden, renal function, and contrast load. (5) Special scenarios: implement mechanism-based pathways for MI with non-obstructive coronary arteries and spontaneous coronary artery dissection (SCAD), incorporating intracoronary imaging, functional testing, vasospasm provocation, and cardiac magnetic resonance imaging; prefer conservative treatment for SCAD unless ongoing ischemia persists. The document provides concise "do" statements, and a summary of changes from 2021 to facilitate bedside adoption. These recommendations aim to standardize high-value, patient-centered ACS care in Korea, reduce practice variability, and improve outcomes while acknowledging areas requiring further evidence.