Acute myocardial infarction and multivessel disease: some vessels are more equal than others

Some of the most complex revascularisation decisions can be encountered in patients with multivessel coronary artery disease and an acute myocardial infarction (MI). In treating such patients, we have to clinically balance evidence from two separately studied patient groups. Acute MI studies have focused primarily on speed of reperfusion with the clear goal of amplifying myocardial preservation and improving mortality. There are many trials and registries that have investigated non-urgent revascularisation of patients with multivessel coronary artery disease. The main message has been that percutaneous coronary intervention (PCI) and bypass surgery yield relatively similar rates of death/MI, with more repeat procedures with the former and more strokes with the latter technique. Furthermore, previous studies have shown that complete revascularisation is predictive of superior clinical outcomes compared with incomplete revasularisation in both coronary artery bypass grafing (CABG) and PCI. In general, the presence of a chronic total occlusion (CTO) has been identified as the main reason for incomplete revascularisation with PCI, and the use of drug-eluting stents has increased complete revascularisation attempts.1 2 However, none of the above clinical studies addresses the clinically important problem of a patient presenting with acute MI and multivessel disease in need of emergency revascularisation. Whenever faced with this scenario, clinicians are trying to follow practice guidelines mainly derived from expert consensus. Currently, for patients presenting with cardiogenic shock (a small minority), immediate revascularisation of all the target lesions/vessels is advised.3 In this subgroup, improved pharmacotherapy and the increasing ability to support the failing left ventricle have facilitated intervention and improved prognosis. For the …