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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline January 18, 2022 Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 e36 CLINICAL STATEMENTS AND GUIDELINES Synopsis A Heart Team approach is utilized to determine optimal revascularization strategy in patients with STEMI and multivessel CAD. Revascularization strategies (Figure 4) for patients with STEMI and multivessel disease include multivessel PCI at the time of primary PCI, PCI of the infarct artery only followed by staged PCI of a non-infarct artery, PCI of the infarct artery only with an ischemiaguided approach to treatment of a non-infarct artery, or PCI of the infarct artery only with elective CABG. Observational studies and meta-analyses have reported conflicting results for the superiority of one approach over another.11 Recent randomized trials of PCI in STEMI support the safety and efficacy of multivessel PCI in selected patients with STEMI.2-4,6,7 The data are strongest for patients undergoing staged PCI.4 It should be noted that only one-third of enrolled patients in these trials had triple-vessel disease, and most of these trials excluded patients with left main disease, chronic total occlusion (CTO) of the non-infarct artery, or complex non-infarct artery disease. For this reason, CABG remains a reasonable option in patients with residual complex non-infarct artery disease. Ideal patients who may benefit from revascularization of non-infarct arteries include those with a large area of myocardium at risk and those without significant comorbidities that would increase the risk of revascularization. Recommendation-Specific Supportive Text 1. RCTs have demonstrated a reduction in MACE with staged PCI (either in hospital or after discharge) compared with culprit vessel–only PCI.1-4 This benefit is driven largely by a reduction in the risk of repeat revascularization or re-infarction. Most recently, the COMPLETE (Complete versus Culprit-Only Revascularization Strategies to Treat Multivessel Disease after Early PCI for STEMI) trial enrolled 4041 patients and demonstrated a 3-year reduction in the combined endpoint of death or MI with staged PCI of the non-infarct artery (performed within 45 days of STEMI), compared with conservative care.4 These benefits were consistent, irrespective of the timing of the non-infarct artery PCI.12 Most of these trials included patients with low-complexity disease. No trial has shown a difference in the outcome of mortality rate alone between the strategies. In the COMPLETE trial, <1% of enrolled patients had non-infarct artery disease involving the left main artery, and the baseline SYNTAX score of the enrolled patients was low. Additionally, these trials enrolled patients with lesions that had a >70% diameter stenosis. For intermediate lesions, physiological testing with iFR or FFR may be useful to guide PCI.4 2. In patients with STEMI and complex multivessel CAD, elective CABG remains an appropriate revascularization option after successful PCI of an infarct artery in patients who meet criteria for CABG (Table 7). Although the COMPLETE trial demonstrated that staged PCI of the non-infarct artery is associated with a reduction in the risk of death or recurrent infarction in follow-up, patients intended for a planned surgical revascularization procedure were not included in this study. In patients with complex non-infarct artery disease, the decision to proceed with PCI versus CABG of the non-infarct artery should include a Heart Team discussion. 3. Randomized trials have shown a reduction in MACE with a multivessel PCI strategy performed at the time of primary PCI as compared with culprit artery–only PCI.1,2,5-7 The benefits reported in these trials were driven largely by a reduction in repeat revascularization with multivessel PCI. PCI of a non-infarct artery stenosis may be considered at the time of successful primary PCI, but patients should be carefully selected. Patients who are most appropriate for complete revascularization at the time of primary PCI include those with uncomplicated PCI of the infarct artery and with low-complexity non-infarct artery disease who have normal left ventricular filling pressures and normal renal function. Clinicians should integrate clinical data, lesion severity and complexity, patient stability, risk of volume overload, and risk of contrast nephropathy before embarking on an immediate multivessel primary PCI strategy. 4. Culprit vessel–only primary PCI is recommended as the primary PCI strategy in most patients with STEMI complicated by cardiogenic shock who have multivessel disease. This is based on consistent findings from observational data and 1 randomized trial that showed no advantage for immediate multivessel PCI.8-10 In the CULPRIT-SHOCK (Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock) trial of patients with acute MI (AMI) complicated by cardiogenic shock, multivessel PCI at the time of primary PCI resulted in a higher risk of the primary endpoint of death or need for renal replacement therapy.8,9 Of note, in this trial, investigators were permitted to proceed with PCI of all non-infarct vessels with >70% diameter stenosis that were ≥2 mm in diameter, including those that were chronically occluded. The risks associated with immediate multivessel PCI include volume overload, contrast nephropathy, and ischemic complications in the non-infarct artery that could cause further hemodynamic deterioration. Downloaded from http://ahajournals.org by on October 7, 2026