Key result
Plaque-guided non-culprit PCI emerges for multivessel STEMI, but clinical benefit awaits trial confirmation.
Why the study?
Substantial residual cardiovascular risk persists in STEMI patients with multivessel disease despite complete revascularization based solely on stenosis severity or ischemia, as many subsequent acute coronary syndromes originate from biologically high-risk, non-flow-limiting non-culprit plaques.
Does plaque-guided preventive PCI of high-risk non-culprit lesions improve clinically meaningful cardiovascular outcomes beyond contemporary revascularization and optimal medical therapy in patients with STEMI and multivessel coronary artery disease?
Does plaque-guided preventive PCI of high-risk non-culprit lesions improve clinically meaningful cardiovascular outcomes beyond contemporary revascularization and optimal medical therapy in patients with STEMI and multivessel coronary artery disease?
Answers are grounded in this paper and cite their sources.
This review highlights the transition in multivessel STEMI management from ischemia-guided complete revascularization toward imaging-guided preventive PCI of vulnerable non-culprit plaques to reduce residual cardiovascular risk.
Complete revascularization is the preferred treatment strategy for hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease. However, substantial residual cardiovascular risk persists despite successful treatment of angiographically or physiologically significant lesions, highlighting the limitations of revascularization strategies based solely on stenosis severity or ischemia. Increasing evidence demonstrates that many subsequent acute coronary syndromes originate from biologically high-risk, non-flow-limiting non-culprit plaques rather than flow-limiting lesions. In this review, we discuss the evolution of STEMI management from the recent focus on complete revascularization toward plaque-guided strategies, including the role of invasive and non-invasive imaging for vulnerable plaque assessment, the emerging evidence supporting preventive PCI of high-risk non-culprit lesions, and ongoing clinical trials shaping this field. Collectively, these advances provide a framework for investigating precision revascularization strategies that integrate plaque morphology, coronary physiology, multimodality imaging, and patient-level cardiovascular risk. Ongoing randomized trials are essential to determine whether plaque-guided preventive intervention improves clinically meaningful outcomes beyond contemporary approaches to revascularization and optimal medical therapy.
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Madanat et al. (2026) conducted a review in ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease. Plaque-guided preventive PCI of high-risk non-culprit lesions vs. Contemporary complete revascularization based on stenosis severity or ischemia and optimal medical therapy was evaluated on Subsequent acute coronary syndromes and clinically meaningful cardiovascular outcomes. Plaque-guided preventive PCI of high-risk non-culprit lesions is an emerging strategy in multivessel STEMI, though ongoing randomized trials are needed to establish clinical benefit.
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