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procedure should be restricted to the IRA only.404 In the CULPRIT-SHOCK trial, IRA-only PCI was associated with a significant reduction in all-cause death or renal replacement therapy at 30-day follow-up (RR 0.83, 95% CI, 0.71–0.96).404 At 1-year follow-up, mortality did not differ significantly between the two groups.505 For patients undergoing emergency CABG, appropriate perioperative strategies (particularly in relation to prophylactic or ondemand mechanical circulatory support) may be considered based on pre-operative clinical status (e.g. age, comorbidities, electrical instability, the extent of jeopardized myocardium, the duration of ischaemia from the time of symptom onset, right ventricular involvement, and the feasibility of cardiac surgery from technical/logistical perspectives). Figure 14 shows the algorithm for the management of patients with ACS and MVD. 10.2 Patients with multivessel coronary

artery disease undergoing primary percutaneous coronary intervention Multivessel disease is evident in approximately half of patients undergoing PPCI and is associated with an adverse prognosis.506,507 Over the past decade, a series of RCTs have provided clinical evidence that supports preventive revascularization of non-IRA after successful PPCI of the IRA. The pivotal clinical trials (in chronological order) include PRAMI (Preventive Angioplasty in Myocardial Infarction), CvLPRIT (Complete versus Lesion-only Primary PCI Trial), DANAMI-3– PRIMULTI (Third Danish Study of Optimal Acute Treatment of Patients with ST-Segment Elevation Myocardial Infarction—Primary PCI in Multivessel Disease), COMPARE-ACUTE (Comparison

Cardiogenic shock STEMI

Patient with ACS undergoing PCI of IRA with an angiographically significant stenosis in ≥ 1 non-IRA

Complete revascularization,

either during the index

procedure or within

45 daysa (Class I) NSTE-ACS

Immediate PCI of IRA only

(Class I)

Staged complete revascularization

(Class IIa) Complete revascularizationb

(Class IIa) Functional invasive evaluation of the non-IRA during the index procedure

(Class IIb)

Figure 14 Algorithm for the management of acute coronary syndrome patients with multivessel coronary artery disease. CABG, coronary artery bypass grafting; IRA, infarct-related artery; MVD, multivessel disease; NSTE-ACS, non-ST-elevation acute coronary syndrome; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; TIMI, Thrombolysis In Myocardial Infarction.aIn patients presenting with STEMI and MVD without CS, complete revascularization either during the index PCI procedure or within 45 days, with PCI of non-IRA based on angiographic severity, is recommended. bIn patients presenting with NSTE-ACS and MVD, complete revascularization, preferably during the index procedure should be considered. Functional invasive evaluation of non-IRA severity during the index procedure may be considered. Downloaded from academic.oup.com/eurheartj/article/44/38/3720/7243210 by guest on 07 October 2026