Key result
Complete revascularization beats culprit-only PCI to reduce recurrent ischemic events in stable multivessel STEMI.
Why the study?
Despite shifts toward complete revascularization in STEMI, questions remain unresolved regarding non-culprit lesion selection criteria, imaging or physiology guidance, timing, and cardiogenic shock management.
Does complete revascularization improve clinical outcomes compared to culprit-lesion-only PCI in hemodynamically stable STEMI patients with multivessel coronary artery disease?
Does complete revascularization improve clinical outcomes compared to culprit-lesion-only PCI in hemodynamically stable STEMI patients with multivessel coronary artery disease?
Supports complete revascularization in stable multivessel STEMI; leaves open optimal timing and guidance strategy.
Multivessel coronary artery disease is observed in a substantial proportion of patients presenting with ST-segment elevation myocardial infarction (STEMI) and identifies a higher-risk phenotype characterized by larger atherosclerotic burden, recurrent ischemic events, and greater need for subsequent revascularization. Over the past decade, randomized evidence has progressively shifted the interventional paradigm from culprit-lesion-only primary percutaneous coronary intervention (PCI) toward complete revascularization in hemodynamically stable STEMI patients with suitable non-culprit lesions. Nevertheless, several clinically relevant questions remain unresolved, including the optimal criteria for selecting non-culprit lesions, the relative value of angiography, coronary physiology, and intracoronary imaging, the timing of complete revascularization, and the management of patients presenting with cardiogenic shock. Angiography-guided complete revascularization has the strongest evidence base, while physiology-guided approaches may reduce unnecessary PCI but have not demonstrated superiority over angiography-guided strategies in direct randomized comparisons. Intracoronary imaging offers unique information on plaque vulnerability and PCI optimization, although dedicated outcome trials in STEMI remain limited. The timing of complete revascularization has also evolved, with contemporary trials supporting early treatment in selected stable patients but not establishing a universal immediate strategy. This review summarizes current evidence, unresolved controversies, and emerging directions regarding strategies and timing of complete revascularization in STEMI patients with multivessel disease.
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Castiello et al. (2026) conducted a review in STEMI with multivessel coronary artery disease. Complete revascularization vs. Culprit-lesion-only primary PCI was evaluated. Current evidence supports complete revascularization over culprit-only PCI in hemodynamically stable STEMI patients with multivessel disease to reduce recurrent ischemic events.
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