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CLINICAL STATEMENTS AND GUIDELINES

April 1, 2025 Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 e812

prehensive view of the vessel wall, allowing for the evaluation of plaque burden, calcification extent, lesion length, and external elastic lamina diameter before stent placement. It also facilitates the assessment of minimum stent area, malapposition, underexpansion, tissue protrusion, edge disease, and edge dissection after stent deployment.14 OCT utilizes infrared light to produce high-resolution images of the vessel wall, offering specific advantages in assessing calcium thickness, lipid presence, thrombus formation, fibroatheroma, and plaque rupture, which is particularly helpful in patients with ACS. It is also useful for examining stent strut neointimal thickness, apposition, and edge dissections. However, it has limitations regarding imaging depth and requires the injection of contrast to clear blood, limiting its utility in cases of ostial left main disease. Both IVUS and OCT play essential roles in evaluating the necessity for lesion preparation, choosing the appropriate stent size, reducing the likelihood of geographical errors, confirming proper stent expansion, identifying complications, and determining the underlying reasons for stent failure.14,15

Recommendation-Specific Supportive Text

1 Randomized trials including patients with ACS

have shown that intracoronary imaging guidance is associated with lower risk of target vessel failure (cardiac death, target vessel MI, or ischemia-driven target vessel revascularization) in patients undergoing PCI.1–4 The advantages of intracoronary imaging are sustained over time and can be extended to less complex lesions.5 Renovate-Complex PCI (Randomized Controlled Trial of Intravascular Imaging Guidance versus Angiography-Guidance on Clinical Outcomes after Complex Percutaneous Coronary Intervention) demonstrated a significant reduction in target vessel failure with intracoronary guidance (IVUS or OCT) versus angiographic guidance after a median follow-up of 2.1 years.1 The OCTOBER (Optical Coherence Tomography Optimized Bifurcation Event Reduction) trial showed a significant reduction in target vessel failure at 2 years with OCT versus angiographic guidance in bifurcation lesions, including left main bifurcations.4 Randomized trials directly comparing OCT versus IVUS have demonstrated that OCT is noninferior to IVUS for PCI-guidance.6–8,10 However, the ILUMIEN IV: Optimal PCI (OCT Guided Coronary Stent Implantation Compared with Angiography) trial, the largest trial testing the strategy of imaging guidance with OCT, did not reveal a difference in target vessel failure with OCT in high-risk patients or patients with high-risk lesions; however, the coprimary endpoint of minimal stent area was significantly larger with OCT guidance compared with angiography guidance.2 The rates of definite or probable stent thrombosis were also significantly lower with OCT-guided PCI compared with angiography-guided PCI. A minimum stent area of <4.5 to 5.0 mm2 by OCT is considered to be an independent predictor of MACE.16,17 Two large network meta-analyses showed that, in aggregate, intracoronary imaging guidance (with either IVUS or OCT) for PCI decreases cardiac death, target vessel MI, target lesion revascularization, and stent thrombosis.11,18

7.4 Management of Multivessel CAD in ACS

7.4.1 Management of Multivessel CAD in STEMI

Recommendations for Management of Multivessel CAD in STEMI Referenced studies that support recommendations are summarized in the Evidence Table.

COR LOE Recommendations

1 A 1 In selected, hemodynamically stable patients with

STEMI and multivessel disease (MVD), after successful PCI of the infarct-related artery, PCI of significantly stenosed* noninfarct-related arteries is recommended to reduce the risk of death or MI and improve angina-related quality of life (QOL).†1–9

2a C-EO 2 In appropriate patients with STEMI and complex

MVD, after successful PCI of the infarct-related artery, elective CABG surgery for significantly stenosed noninfarct-related arteries involving the left anterior descending artery or left main disease is reasonable to reduce the risk of cardiovascular events.†

2b B-R 3 In selected hemodynamically stable patients

with STEMI and low-complexity MVD (those not intended for CABG surgery), multivessel PCI of significantly stenosed noninfarct-related arteries at the time of PPCI may be preferred over a staged approach to reduce the risk of cardiovascular events.10–12

3: Harm B-R 4 In patients with STEMI complicated by cardiogenic

shock, routine PCI of a noninfarct-related artery at the time of PPCI should not be performed because of the higher risk of death or renal failure.*13–15

*Significantly stenosed refers to lesions that are severely diseased as defined by the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization” as a visually estimated diameter stenosis severity of ≥70% for non–left main disease and ≥50% for left main disease.16 †Modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”16

Synopsis Several randomized trials of hemodynamically stable patients with STEMI have demonstrated that a strategy of multivessel PCI of significantly stenosed nonculprit vessels is safe and reduces risk of MACE when compared with PCI of the infarct-related artery alone.1–8 These trials enrolled a select group of patients with anatomy suitable for PCI and without clinical factors precluding further invasive therapies. Recent studies suggest a lower risk of MACE (predominantly driven by a lower rate of recurrent ischemia and recurrent MI) when multivessel stent-

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