2021 ACC/AHA/SCAI Coronary Artery Revascularization Guidelines for Managing the Nonculprit Artery in STEMI

The 2021 Coronary Artery Disease revascularization guidelines of the American College of Cardiology (ACC), the American Heart Association (AHA), and the Society for Cardiovascular Angiography and Interventions (SCAI) provide recommendations for managing nonculprit arteries in ST-segment elevation myocardial infarction (STEMI). Although staged revascularization is preferred, at times same-setting intervention, coronary artery bypass surgery, or medical therapy may be preferable. These cases exemplify clinical scenarios for treating nonculprit arteries in STEMI. (Level of Difficulty: Intermediate.)

T he management of multivessel coronary artery disease in patients with ST-segment elevation myocardial infarction (STEMI) who have received successful treatment of a culprit artery has evolved considerably over the past decade.
The results of randomized trials [1][2][3][4][5][6] have had an impact on the approach advocated by the 2021 coronary artery revascularization guidelines of the American College of Cardiology (ACC), the American Heart Association (AHA), and the Society for Cardiovascular Angiography and Interventions (SCAI) ( Table 1). 7 In meta-analyses, incorporating the recently published COMPLETE trial (Complete versus Culprit-Only Revascularization Strategies to Treat Multivessel Disease after Early PCI for STEMI), which randomized >4,000 patients, 1 multivessel revascularization reduced major adverse cardiovascular events in comparison with percutaneous coronary intervention (PCI) of only the culprit artery. 8,9 The benefit of multivessel revascularization in specific clinical situa-  Figure 1B) and an eccentric ulcerated 80% mid-left anterior descending (LAD) stenosis with a small, diffusely diseased LAD ( Figure 1C).
A temporary pacing wire was placed. The mid-RCA lesion was thrombotic with recanalization and was stented ( Figure 1B). The patient's hypotension and bradycardia resolved.
An ischemia-guided approach to evaluate the diffusely diseased LAD was planned, but on the third day after STEMI she experienced an episode of typical chest pain with nonspecific T-wave changes on electrocardiogram. She underwent PCI of the eccentric ulcerated 80% mid-LAD stenosis; the distal LAD was very small, with only moderate atherosclerosis on intravascular ultrasound, and did not undergo intervention ( Figure 1C). The patient's angina resolved, and she is free from cardiovascular events for the past 2 years.
This case illustrates a successful staged PCI of a nonculprit artery. The 2021 ACC/AHA/SCAI revascularization guidelines provide a class 1, level of evidence (LOA) A ("is recommended to reduce the risk of death or myocardial infarction) for staged PCI. 7 In this case, staged PCI was initially deferred owing to lesion complexity and the patient's initial hemodynamic instability.

CARDIOGENIC SHOCK
A 74-year-old man with diabetes, hypertension, prior PCI, renal cancer resection, and renal failure presented with ongoing chest pain for several weeks and an anterior STEMI ( Figure 2A).
Stenting of the mid and proximal LAD was performed. Immediately after PCI, the patient experienced no-reflow in the distal LAD (Video 1), causing hemodynamic instability and ventricular fibrillation.
He remained in severe cardiogenic shock despite defibrillation, cardiopulmonary resuscitation, vasopressors, and an intra-aortic balloon pump and subsequently an Impella (Abiomed) ventricular assist device. Despite the technically successful LAD PCI with subsequent TIMI flow grade 3 ( Figure 2B, Video 2), the patient's cardiogenic shock progressed (BP 65/39 mm Hg, heart rate 103 beats/min), requiring increasing ionotropic and vasopressor support. PCI of the circumflex as a same-setting procedure was thus used ( Figure 2C), and the patient's condition stabilized. The residual OM1 and RCA lesions were not treated immediately, but PCI of his OM1 was required before discharge ( Figure 2D).
The patient was discharged free of chest pain but with an ejection fraction of 30% and is being treated for heart failure.
The 2021 ACC/AHA/SCAI coronary artery revascularization guidelines provide a class 3-harm, LOE-B-R recommendation ("should not be performed because of the higher risk of death or renal failure") for routine multivessel PCI at the time of primary PCI in

Noninfarct Artery Revascularization in Patients With STEMI
A P R I L 6 , 2 0 2 2 : 3 7 7 -3 8 4 patients with STEMI complicated by cardiogenic shock. 7 In context of the large circumflex territory contributing to severe refractory shock, however, PCI of this lesion was considered urgent in our clinical judgment and helped stabilize the patient's condition.
The RCA was successfully opened, but the patient experienced ventricular fibrillation, which was successfully defibrillated. He required a transvenous pacemaker for sinus bradycardia and an intra-aortic balloon pump for biventricular dysfunction. The patient's condition stabilized, but revascularization of   washington.edu. Noninfarct Artery Revascularization in Patients With STEMI