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CLINICAL STATEMENTS AND GUIDELINES

April 1, 2025 Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 e814

procedure approach for immediate multivessel PCI was preferred followed by staged multivessel PCI.12 Patients ideally suited for immediate complete revascularization include those with uncomplicated PCI of the infarct-related artery and low complexity noninfarct-related artery disease with stable hemodynamics, normal LV filling pressures, and normal renal function. 4.	 In patients with STEMI complicated by cardiogenic

shock and MVD, a strategy of multivessel PCI is associated with worse outcomes.13–15 The CULPRIT- SHOCK (Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock) trial13 randomized 706 patients with AMI, approximately 60% with STEMI, and cardiogenic shock to a strategy of complete multivessel PCI or culprit vessel–only PCI. At 30 days and 1 year, the rates of death or need for renal replacement therapy were significantly higher in the group of patients randomized to multivessel PCI.13,14 Importantly, the CULPRIT-SHOCK trial only permitted enrollment if there was an identifiable culprit lesion. In situations where an unstable-appearing nonculprit artery lesion was observed, or in those patients with an uncertain culprit lesion, the decision to proceed with multivessel PCI may be more nuanced.

7.4.2 Management of Multivessel CAD in NSTE-ACS

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

COR LOE Recommendations

1 C-EO 1 In patients with NSTE-ACS with MVD, the mode

of revascularization (CABG or multivessel PCI) should be based on the disease complexity and patient’s comorbidities.

Multivessel CAD and Candidates for PCI

1 B-R 2 In stable patients with NSTE-ACS with MVD but

without left main stenosis who are not intended for CABG surgery and undergoing culprit-lesion PCI, PCI of significant nonculprit lesions (at the time of the index procedure or as a staged procedure) is recommended to reduce the risk of MACE.1–6

2b B-R 3 In patients with NSTE-ACS in whom multivessel

PCI is being considered, physiological assessment of a nonculprit stenosis may be considered to guide revascularization decisions.7–9

3: Harm B-R 4 In patients with NSTE-ACS complicated by

cardiogenic shock, routine PCI of a nonculprit artery at the time of index procedure should not be performed because of the higher risk of death or kidney failure.*10,11

*Modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”12

Synopsis Multivessel coronary disease, defined as angiographically significant stenosis (≥50%) in ≥2 epicardial arteries, is present in up to 40% to 70% of patients with NSTE-ACS. Identification of the culprit artery in these situations might be challenging.13 Several subsets of patients, including those with complex left main disease, complex 3-vessel disease, and diabetes with left anterior descending artery involvement, might be appropriate for CABG surgery.12 A Heart Team approach is recommended to consider CABG surgery versus multivessel PCI based on the complexity of CAD, technical feasibility, patient's surgical risk, and the potential for rehabilitation after CABG surgery. Dedicated RCTs comparing multivessel PCI versus culprit-only PCI exclusively among hemodynamically stable patients with NSTE-ACS are lacking. A large subgroup analysis from an RCT that included both patients with STEMI and NSTE-ACS and several observational studies have suggested that multivessel PCI among selected patients not intended for CABG reduces risk of MACE.1–4,6,15 Angiographic assessment might overestimate the severity of a nonculprit lesion.16 In one study, routine integration of physiological assessment of a nonculprit artery stenosis in NSTE-ACS led to change in management (ie, from revascularization to medical treatment only) in 38% of the cases.17

Recommendation-Specific Supportive Text

1 Studies evaluating the benefit of multivessel

PCI among patients with NSTE-ACS and MVD excluded patients planned for CABG. The potential benefit of multivessel PCI cannot be extrapolated to patients with complex CAD. Indeed, certain subsets of patients might derive a survival benefit from CABG, including those with diabetes and disease involving the left anterior descending artery, left main with high complexity, MVD with complex or diffuse CAD, and those with severe LV dysfunction (Table 16).18–21 Accordingly, a Heart Team approach is recommended to consider CABG surgery versus multivessel PCI based on the complexity of the CAD, technical

Table 16.  Considerations for Choice of Coronary Revascularization Strategy for Patients With NSTE-ACS and MVD In patients with NSTE-ACS and MVD, CABG surgery may be preferred over multivessel PCI in any of the following situations: Significant left main coronary stenosis with high-complexity CAD Multivessel CAD with complex or diffuse CAD Diabetes mellitus and MVD with the involvement of the LAD Multivessel CAD or complex left main CAD with severe left ventricular dysfunction Adapted from the “2021 ACC/AHA/SCAI Coronary Revascularization Guideline.”12 CAD indicates coronary artery disease; CABG, coronary artery bypass grafting; LAD, left anterior descending artery; MVD, multivessel disease; NSTE-ACS, non–ST-segment elevation acute coronary syndromes; and PCI, percutaneous coronary intervention.

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