Invasive treatment in STEMI: PCI of the culprit vessel vs a multivessel approach

Which invasive treatment strategy is preferred in ST-segment elevation myocardial infarction (STEMI): percutaneous coronary intervention (PCI) of the infarct-related artery only or revascularization of all significant lesions?

Zaza Iakobishvili, MD, PhD: Doing multivessel PCI during STEMI presentation was a class III [recommendation], so it was actually contraindicated. In some studies, small studies I have to mention—it is a primary culprit study—cardiologists feel more liberated from these things, and there are some situations when you can do a multivessel intervention, or during the primary PCI itself.^1,2 But most of us are doing these interventions—primary PCI on the culprit vessel only—at an early stage, and 2 or 3 days apart during the same hospitalization we do the job with other severely narrowed arteries.

On the other hand, in cardiogenic shock patients where the multivessel PCI was considered to be standard of care but only on expert opinion, actually this view was challenged—it was even written in the recent guidelines that multivessel PCI by expert opinion should be the routine strategy for cardiogenic shock that complicates STEMI. A study that comes from Germany—a multicenter European study—shows very clearly that the 30-day mortality and renal replacement therapy composite outcome was better in patients who underwent the culprit vessel–only intervention than in patients who underwent multivessel intervention.³ It challenges these guidelines and probably the guidelines must be changed according to this study.

[After the recording of this interview, the European Society of Cardiology guidelines task force published their viewpoint, which incorporates the CULPRIT-SHOCK results in clinical practice.⁴]