p.45 抽出テキスト

CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 April 1, 2025 e815

feasibility, patient’s surgical risk, and the potential for rehabilitation after CABG surgery in these situations. In patients who are deemed appropriate for CABG, surgery could be considered prior to hospital discharge. Several observational studies have suggested that early CABG (performed within 3 days of presentation) may be associated with similar outcomes compared with delayed CABG.22–24

2 The FIRE (Functional Assessment in Elderly MI

Patients With Multivessel Disease) trial enrolled 1445 elderly patients (median age, 80 years) with multivessel disease (ie, nonculprit artery with minimum vessel diameter >2.5 mm and angiography estimated stenosis 50% to 99%) and ACS (∼65% with NSTE-ACS). Multivessel PCI reduced the risk of MACE, as well as reduced all-cause and cardiovascular mortality. The benefit was consistent between patients with NSTE-ACS versus patients with STEMI.1 Several observational studies and a meta-analysis of observational studies demonstrated that multivessel PCI is associated with a lower incidence of long-term MACE.2,3,6 Few RCTs have evaluated the optimal timing of a multivessel PCI approach. The SMILE (Single Staged Versus Multistaged PCI in Multivessel NSTEMI Patients) trial enrolled 584 patients and demonstrated that multivessel PCI conducted in a single procedure reduces risk of MACE at 1 year driven by a lower risk of revascularization.4 The BIOVASC trial randomized 1525 patients with ACS (∼60% with NSTE-ACS) and showed that multivessel PCI in a single procedure was noninferior to staged PCI with respect to MACE at 1 year and without evidence of an interaction between patients with NSTE-ACS versus patients with STEMI.5,25

3 In a secondary analysis including 328 patients with

NSTE-ACS and MVD from the FAME (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) trial that randomized patients to either angiography-guided PCI (if diameter stenosis ≥50%) or FFR-guided PCI (if FFR ≤0.80), FFRguided PCI reduced the number of stents and the incidence of MACE at 2 years.7 The FRAME-AMI (Fractional Flow Reserve vs. Angiography-Guided Strategy for Management of Non-Infarction Related Artery Stenosis in Patients with Acute Myocardial Infarction) trial enrolled 562 patients with ACS and MVD (∼53% with NSTE-ACS) and were randomized to FFR-guided PCI (if FFR ≤0.80) or angiography-guided PCI (diameter stenosis of >50%). FFR-guided PCI reduced the number of stents and the risk of MACE at 3.5 years with no evidence of interaction between patients with NSTE-ACS and patients with STEMI. Of note, the trial was prematurely terminated due to slow recruitment and enrolled <50% of the planned 1292 patients.9 In the FAMOUS-NSTEMI (Fractional Flow Reserve Versus Angiographically Guided Management to Optimise Outcomes in Unstable Coronary Syndromes) trial, which randomized 350 patients with NSTE-ACS and MVD to FFR-guided PCI (if FFR ≤0.80) or angiography-guided PCI (diameter stenosis of >30%), FFR-guided PCI reduced the number of revascularization procedures at 1 year.8

4 In patients with NSTE-ACS complicated by car-

diogenic shock and MVD, multivessel PCI at the time of the index procedure is associated with worse outcomes.10,11 The CULPRIT-SHOCK (Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock) trial randomized 706 patients with AMI and cardiogenic shock (approximately 40% with NSTE-ACS) to multivessel PCI at the time of the index procedure or culprit-only PCI. Multivessel PCI was associated with higher rates of death or need for renal replacement therapy at 30 days and at 1 year.10,11 Notably, the CULPRIT SHOCK trial enrolled only patients with an identifiable culprit lesion. When there is an unstableappearing nonculprit, or uncertain culprit, artery lesion, the decision to proceed with multivessel PCI will be based on the anatomic and clinical circumstances.

8 CARDIOGENIC SHOCK MANAGEMENT

8.1 Revascularization in ACS With Cardiogenic

Shock Recommendations for Revascularization in ACS With Cardiogenic Shock Referenced studies that support recommendations are summarized in the Evidence Table.

COR LOE Recommendations

1 B-R 1 In patients with ACS and cardiogenic shock or

hemodynamic instability, emergency revascularization of the culprit vessel by PCI or with CABG is indicated to improve survival, irrespective of time from symptom onset.1–4

3: Harm B-R 2 In patients with ACS 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.*5–7

*Modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”8

Synopsis In patients with STEMI and hemodynamic instability, treatment delays to PPCI are associated with worse survival.1 In patients with cardiogenic shock, PCI of

Downloaded from http://ahajournals.org by on October 7, 2026