Multi-vessel versus culprit-vessel-only PCI for STEMI: Where does the jury stand?

The annual incidence of myocardial infarctions (MI) in the United States is 1.5 million. Percutaneous coronary intervention (PCI) is a non-surgical procedure whereby a stent is employed to revascularize a blocked coronary vessel. It has become the preferred modality for the treatment of acute ST-segment elevation myocardial infarction (STEMI) [1,2]. In patients presenting with acute coronary syndrome (ACS), the first question that governs the optimal treatment approach is whether there is an obvious culprit lesion for the patient's underlying presentation. If such a lesion is present alongside ongoing ischemia in a STEMI, emergent PCI of the culprit vessel is recommended. Contrarily, if the culprit lesion is present without ongoing ischemia, the extent of coronary artery disease (CAD) must be evaluated to determine the approach: a single-vessel (PCI of culprit) or multivessel (including the left coronary artery) PCI. The culprit lesion is treated first; however, in patients with multiple coronary artery disease, the distal lesions are treated first. Nevertheless, whether multivessel PCI confers a comparative therapeutic advantage over culprit-vessel-only PCI remains enigmatic.