Scientific cardiology has forced us to believe ACS management must be catheter based and all others are inferior and those who pursue the later , carry a risk of being labelled as unethical in near future. However ,experienced cardiologists will know where the truth lies.
Now,in the interventional cardiology board rooms there is a big debate going on regarding the value of early total revascualrisation in STEMI with multivessel CAD.Suddenly , every lesion looks suspect ( Ex,current or future culprit ! ) and all stentable lesion are stented either in an emergency or semi emergency fashion (The new age post PCI dialogue goes something like this “I have tackled one culprit , other one seems to hide in LAD , we will arrest it next 48 hours or so* ? ( This is the concept of deferred or staged non-IRA stenting )
*Ironically it brings one more dubious therapeutic time window in ACS !
The recent studies like PRAMI, PRIMULTY ,CvLPRIT are trying to find out an answer to this issue and suggest acute multivessel PCI may be good strategy. Some of them advocate a FFR guided non IRA intervention , knowing fully well micro-circulatory bed is completely altered by the index acute thrombotic event.( Mind you , for FFR, we need to induce maximum hyperemia with Adenosine in a highly varying local autonomic milleu within the thrombus clogged capillary network)
Final message ( Intentionally biased !)
Till we learn or unlearn it is vital to go with conventional wisdom.Don’t pursue a random hunt for coronary culprits in acute phase of STEMI.Many of them are innocents and likely to suffer in cross fire.Tender coronary arteries need some rest,peace and time to heal thyself . Just keep away , they will definitely say big thanks with folded hands !
1.Gershlick AH, Khan J, Kelly DJ, et al. Randomized Trial of Complete Versus Lesion-Only Revascularization in Patients Undergoing Primary Percutaneous Coronary Intervention for STEMI and Multivessel Disease: The CvLPRIT Trial. J Am Coll Cardiol. 2015;65(10):963-972.