How and When: Complete Revascularization for Acute Coronary Syndromes

e management of multivessel disease in acute coronary syndromes (ACSs) has undergone a remarkable transformation over the past decade.Once, the prevailing wisdom was to treat only the culprit artery during a ST-segment elevation myocardial infarction (STEMI), with guidelines actively discouraging intervention on non-culprit lesions during the ACS presentation.Today, robust randomized controlled trial (RCT) evidence has shifted the paradigm, making complete revascularization not only acceptable but also recommended in most cases. [1,2] THE EVOLUTION OF EVIDENCEEarly United Kingdom-based trials such as preventive angioplasty in acute myocardial infarction (PRAMI) [3] and complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for stemi and multivessel disease (CvLPRIT) [4] challenged the dogma, demonstrating that treating non-culprit lesions during the index admission, and often the index procedure, reduced major adverse cardiovascular events.ese studies, though modest in size, set the stage for larger, more definitive trials.ird danish study of optimal acute treatment of patients with stemi: primary pci in multivessel disease (DANAMI-3 PRIMULTI) [5] and comparison between FFR guided revascularization versus conventional strategy in acute stemi patients with MVD (COMPARE-ACUTE) [6] introduced physiology-guided approaches, using fractional flow reserve (FFR).ese studies further demonstrated the benefit of complete revascularization, primarily through reductions in urgent repeat procedures, but lacking reductions in hard endpoints.e landmark complete versus culprit-only revascularization strategies to treat multivessel disease after early PCI for stemi (COMPLETE) trial [7] provided the clearest answer yet: Complete revascularization significantly reduced cardiovascular death and myocardial infarction compared to culprit-only percutaneous coronary intervention (PCI).is pivotal trial led to a Class I, Level A recommendation in both American and European guidelines, a rare distinction in STEMI management.Most recently, the DANAMI-3 PRIMULTI 10-year follow-up confirmed the sustained durability of the benefit of complete revascularization over culprit-only PCI for ACS patients. [8] TIMING AND STRATEGY: IMMEDIATE VERSUS STAGEDRecent studies have focused on the timing of revascularization.e percutaneous complete revascularization strategies using sirolimus-eluting biodegradable polymer-coated stents in www.ijcdw.