Editorial comment
Non-culprit lesion percutaneous coronary intervention during acute myocardial infarction – the road not taken?

In this issue of “Postępy w Kardiologii Interwencyjnej/Advances in Interventional Cardiology” journal, 1 case report and 1 original article present one of the most hotly debated dilemmas in the current practice of interventional cardiology – the optimal revascularization approach for patients undergoing primary percutaneous coronary interventions (PPCI) for myocardial infarction (MI) and found to have multivessel coronary artery disease (CAD).
The case report by Wolny et a. describes the clinical course of a patient who was admitted directly to the catheterization laboratory due to an inferior wall ST elevation MI (STEMI), as a first presentation of CAD. On angiography, the patient was found to have a two-vessel CAD – an occlusive lesion in the distal right coronary artery (RCA), the culprit lesion in the infarct-related artery (IRA) this context, and a second lesion in the proximal left anterior descending artery (LAD) with involvement of the 1st diagonal branch (the non-IRA lesion) without obstruction of the coronary flow. The patient underwent successful PPCI of the culprit lesion, with resolution of symptoms, and was admitted for continued care, but a few hours later developed anterior MI due to thrombotic occlusion of the LAD stenosis, not treated during the PPCI.
This case raises the obvious question – could the 2nd MI have been avoided by preventive stenting of the non-IRA lesion during the PPCI? The answer to this question is not clear. Currently, such patients present major dilemmas for the interventional cardiologist: patients with multivessel CAD comprise over half of the STEMI population, and their prognosis is worse, compared to patients with single vessel disease [1]. Considering the well-established prognostic benefit from achieving complete revascularization (or at least “reasonable” incomplete revascularization) [2, 3] in CAD patients, it is obvious that the optimal goal is a more aggressive approach leading to more complete revascularization. The question at hand is the optimal timing of revascularization for non-IRA lesions.
Current guidelines [4] based upon a firm base of evidence from large observational studies (in a field that until recently was seriously lacking in randomized trials) [5], which found a significant increase in adverse outcomes for patients undergoing multivessel PCI in the setting of acute MI, recommend a restrictive approach that discourages treatment of non-IRA lesions during the index...


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