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Justification for complete revascularisation at the time of primary angioplasty
  1. I S Malik,
  2. R T Gerber
  1. Imperial College Healthcare NHS Trust, Department of Cardiology, St Mary's Hospital, London, UK
  1. Correspondence to Dr I S Malik, Imperial College Healthcare NHS Trust, Department of Cardiology, St Mary's Hospital, Praed Street, London W2 1NY, UK; iqbal.malik{at}imperial.nhs.uk

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The prevalence of multivessel disease in patients presenting with acute ST-segment elevation myocardial infarction (STEMI) approaches 40%.1 The conventional strategy for coronary angioplasty (primary percutaneous coronary intervention, PPCI) in the setting of STEMI usually involves selective intervention to the infarct-related artery (IRA), or culprit-only revascularisation (COR), with treatment being deferred for significant non-infarct-related lesions (N-IRA) in those patients with multivessel disease.2 This may be either performed as a later staged PCI procedure (staged revascularisation, SR), or postponed indefinitely pending non-invasive assessment of ischaemia and/or symptoms.

Currently, there is no consensus on the optimal management of significant N-IRA lesions. Previously non-randomised comparisons have been made between ‘complete’ revascularisation (CR) with multivessel PCI at the time of PPCI and culprit-only PCI (COR). However, the definitive strategy is still undetermined and the subsequent management of any N-IRA lesions is largely left to operator discretion. Consequently, there is vast heterogeneity in treatment; some routinely do the ‘significant-other’ lesion during that patient's hospital stay, while others perform a non-invasive test to demonstrate the presence of ongoing ischaemia as a means to determine if further revascularisation is indicated.

Why do it?

Acute coronary syndromes, including STEMI, result from an inflammatory process in the majority of cases.3 Multiple unstable atheromatous plaques have been detected during periods of coronary instability.2 Thus, it may be hypothesised that multivessel PCI in the peri-infarct period …

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