Multivessel PCI in STEMI: ready to be the recommended strategy?

Multivessel obstructive coronary artery disease is observed in about half of the STEMI patients undergoing primary PCI. Optimal management of non-culprit lesions in these settings continues to be a matter of debate and no consensus has been reached. Lack of robust scientific data led to significant heterogeneity in practice among different centres and countries. In general, three approaches have been defined in haemodynamically stable patients: an aggressive approach with non-culprit PCI during the index procedure, an intermediate approach with non-culprit PCI or CABG as a staged procedure during the index hospital stay or within 30 days, and a conservative approach with non-culprit PCI/CABG only in case of refractory symptoms or objective detection of ischaemia. Based on available data and subsequent post hoc pooled analysis, an intermediate approach has been considered as an accepted option and often adopted. Conversely, the recent PRAMI study results (Preventive Angioplasty in Acute Myocardial Infarction) suggested that an aggressive approach (including non-culprit PCI during the index procedure) provided better clinical outcome than the conservative "culprit only" approach. It is, however, as yet unknown if the aggressive approach used in the PRAMI study is also better than the traditionally advocated intermediate approach with angiographically or FFR-driven staged non-culprit revascularisation. The purpose of this review is to discuss the available evidence and integrate it into daily clinical decision making.