primary percutaneous coronary intervention ( pci ) is a standard interventional treatment modality for managing patients with st - segment elevation myocardial infarction ( stemi ) .
remarkable advances in pci have been made with the development of interventional technologies and the accumulation of experience by interventional cardiologists in patients with acute myocardial infarction ( ami ) requiring urgent revascularization .
however , several issues can cause difficulties for interventional cardiologists , such as multivessel coronary artery disease ( mvd ) on a diagnostic coronary angiogram , which is seen in 50 - 80% of patients.1)2)3)4 ) more adverse cardiovascular events occur in patients with mvd than those without mvd , and a lack of accurate guidelines makes it difficult for cardiologists to determine the extent of revascularization.5)6 ) two interventional strategies have been used for managing stemi with mvd .
infarct - related or culprit vessel - only revascularization ( cvr ) is an intervention of the infarct - related artery ( ira ) only ; no other diseased vessels are targeted , regardless of their significance .
the other strategy is multivessel revascularization ( mvr ) , defined as an intervention of more than one significant stenotic vessel .
it includes treating all diseased vessels , referred to as complete revascularization , and is divided into " staged " ( ira intervention followed by elective second staged non - ira revascularization ) and ad hoc ( simultaneous ira and non - ira intervention during an index procedure ) pci based on the timing of the non - ira intervention .
the potential disadvantages of multivessel intervention should also be considered , such as the risk of contrast - induced nephropathy , radiation exposure , the development of stent thrombosis or other periprocedural complications , and the risk of ongoing ischemia by remnant lesions.7 ) in addition , cardiogenic shock at initial presentation can affect the pci strategy in patients with stemi .
there are still limited data on the optimal pci strategy in patients with mvd presenting with stemi .
this review describes the current status of mvr in stemi patients based on recently published data and proposes an optimal revascularization strategy .
the current american college of cardiology / american heart association ( acc / aha ) and european revascularization guidelines for stemi recommend cvr during primary pci as the primary interventional strategy in patients with mvd.8)9 ) although cvr is a universally accepted treatment modality in stemi patients , several studies have shown the efficacy of simultaneous ira and non - ira intervention during primary ad hoc pci and a staged pci procedure . culprit vessel - only revascularization is an interventional strategy that revascularizes only the ira during primary pci , regardless of the significance of non - iras . thus , it is a conservative management approach that allows for revascularization of the ira only followed by medical therapy , and some studies have shown more favorable outcomes of cvr than mvr during primary pci .
an early study by roe et al.10 ) described increased 6-month mortality and major adverse cardiac events ( maces ) with mvr .
corpus et al.5 ) analyzed 506 patients with mvd ; 152 were treated with mvr and 354 were treated with cvr during primary pci .
mvr was associated with higher rates or re - infarction ( 13.0% vs. 2.8% , p<0.001 ) , revascularization ( 25.0% vs. 15.0% , p=0.007 ) , and composite mace
( 40.0% vs. 28.0% , p=0.006 ) compared to cvr after 1-year of clinical follow - up .
a recent analysis of the apex - ami trial11 ) examined the incidence of cvr during primary pci and 90-day outcomes compared to mvr . among 2210 patients with mvd , only 217 ( 9.9% ) underwent cvr . death and death
/ congestive heart failure / shock after 90-days was significantly higher in the mvr group than that in the cvr group ( 12.5% vs. 5.6% , p<0.001 and 17.4% vs. 12.0% , p=0.020 , respectively ) .
furthermore , mvr was associated with an increased risk of 90-day mortality { adjusted hazard ratio ( hr ) 2.44 ; 95% confidence interval ( ci ) , 1.55 - 3.83 ; p<0.001 } after adjusting for patient and procedural characteristics , as well as the propensity for mvr .
dziewierz et al.12 ) reported that non - ira pci during an index procedure in patients with stemi and mvd is associated with increased 1-year mortality in a registry database ( european registry on patients with st - elevation mi transferred for mechanical reperfusion with a special focus on upstream use of abciximab ; eurotransfer ) .
recent studies also showed inferior clinical outcomes of mvr compared to patients who received cvr during primary pci,13)14 ) and the meta - analysis of vlaar et al.15 ) revealed higher mortality rates of patients who underwent mvr during long - term follow - up compared to cvr or a staged pci group .
limited data show the benefits of simultaneous ira and non - ira intervention during primary pci .
although several early studies supported the superiority of mvr over cvr , they included only a small number of patients and were not randomized.16)17)18 ) politi et al.19 ) performed a randomized trial assessing the outcomes of 214 patients with stemi and mvd undergoing primary pci .
all patients were randomized before angioplasty into cvr , ad hoc mvr , and staged pci groups . during a mean follow - up of 2.5 years
, there were more maces in the cvr group ( 50% of patients ) than those in the mvr ( 23% ) and staged pci ( 20% ) groups .
bangalore et al.20 ) performed a meta - analysis of 61764 subjects with stemi and mvd in 19 studies with 23 arms , and associated mvr with a 44% decrease in repeat pci and maces { odds ratio ( or ) , 0.68 ; 95% ci , 0.57 - 0.81 } for early outcomes within 30 days , despite similar mortality , mi , stroke , and target vessel revascularization . no differences related to mi , target vessel revascularization , or stent thrombosis were observed for long - term outcomes , with a decreased risk of mortality , repeat pci , coronary artery bypass surgery , and mace ( or , 0.60 ; 95% ci , 0.50 - 0.72 ) with mvr .
however , that study was limited because it was a non - randomized trial that included only two randomized controlled trials in the meta - analysis . a recent trial by wald et al.21 ) randomized 465 patients with stemi who underwent primary pci into two groups : preventive pci ( 234 patients ) or no preventive pci ( 231 patients ) .
primary outcomes were composite cardiac deaths , non - fatal mi , and refractory angina . during a mean follow - up of 23 months , primary outcomes occurred more often in the no preventive pci group ( hr , 0.35 ; p<0.001 ) and the hrs were 0.34 for cardiac death , 0.32 for non - fatal mi , and 0.35 for refractory angina .
they concluded that preventive pci in non - ira significantly reduced the risk of mace compared to cvr in patients with stemi who underwent primary pci . in a large - scale korean registry
( korea acute myocardial infarction registry , kamir ) , two recent studies evaluated the efficacy of mvr in patients with stemi and mvd.22)23 ) jo et al.22 ) analyzed 1094 stemi patients with mvd who underwent primary pci with drug - eluting stents ( 827 in the cvr and 267 in the mvr groups ) . during a 1-year follow - up ,
mace rates were similar in the cvr ( 15.2% ) and mvr ( 14.2% ) groups , despite higher in - hospital mortality in the cvr group ( 5.2% vs. 0.4% , p<0.001 ) . in subgroup analyses between complete ( n=182 ) and incomplete ( n=912 ) revascularized patients , the former had a lower 1-year mace rate ( 9.5% vs. 15.0% , p=0.039 ) primarily driven by the non - target vessel repeat pci rate ( 1.8% vs. 8.6% , p=0.002 ) .
however , complete revascularization was associated with a lower rate of non - target vessel repeat revascularization during the follow - up period after multivessel pci in subgroup analyses .
lee et al.23 ) also compared cvr ( 1106 patients ) with mvr ( 538 patients ) in 1644 stemi and mvd patients who received primary pci using stent implantation or balloon angioplasty .
inhospital outcomes such as mortality , complications , acute kidney injury , major bleeding , and new onset heart failure were similar between the two groups , except for the development of fatal ventricular arrhythmia ( 4.5% vs. 2.4% , p=0.037 ) . at 1 month , the occurrence of mace was not different between the two groups .
the mace rate at 1 year was also similar between both groups ; however , the target - lesion repeat pci rate was higher in the mvr group ( 2.4% vs. 5.9% , p<0.0001 ) . therefore , they concluded that there were no significant differences in clinical outcomes between the groups , except for a higher risk of target lesion revascularization in the mvr group .
these two kamir studies showed similar results in that mvr was not superior to cvr in patients with stemi and mvd .
however , the 1-year repeat target - lesion pci rate was higher in the mvr group in the latter study , which might be associated with a higher proportion of bare - metal stents implanted in the study population ( 8.7% in the cvr group and 11.0% in the mvr group ) , as well as other angiographic factors .
however , limited information on staged pci and a lack of detailed angiographic anatomies in these studies may have underestimated the outcomes .
although some studies have shown superiority of mvr in patients with stemi , the results have been limited by changes in standard interventional strategies of primary pci .
although there is no definitive evidence that mvr is superior to cvr , and the current guidelines support cvr during primary pci , several recent studies have suggested that staged multivessel pci can be an alternative interventional strategy to achieve optimal clinical outcomes .
hannan et al.13 ) showed that culprit vessel pci during the index procedure for patients without hemodynamic compromise is associated with lower in - hospital mortality than multivessel pci during the index procedure ( 0.9% vs. 2.4% , p=0.04 ) .
interestingly , patients who underwent staged multivessel pci within 60 days after the index procedure had a significantly lower 12-month mortality rate than those who underwent culprit vessel pci only ( 1.3% vs. 3.3% , p=0.04 ) .
vlaar et al.15 ) performed a meta - analysis including four prospective and 14 retrospective studies involving 40280 patients .
their analysis favored a staged pci strategy with complete revascularization . among different interventional strategy groups , staged pci was associated with lower short- and long - term mortality compared to cvr and ad hoc mvr , and the mvr group showed the highest mortality rates at both short- and long - term follow - ups .
another study supported the use of staged pci . a subgroup analysis in the harmonizing outcomes with revascularization and stents in acute myocardial infarction trial ( horizons - ami)24 ) compared cvr to staged pci ; the results indicated higher 1-year mortality ( 9.2% vs. 2.3% ; hr , 4.10 ) , cardiac death ( 6.2% vs. 2.0% ; hr , 3.14 ) , and stent thrombosis ( 5.7% vs. 2.3% ; hr , 2.49 ) in the cvr group than those in the staged pci group .
furthermore , there was a trend toward higher 1-year adverse cardiac events ( 18.1% vs. 13.4% ; hr 1.42 ; p=0.08 ) in the former group .
jensen et al.25 ) also reported that staged multivessel pci within 60 days after index hospitalization can reduce 1-year mortality compared to patients who undergo cvr during primary pci ( hr , 0.28 ; 95% ci , 0.14 - 0.54 ) .
taken together , these results indicate that staged pci is promising , and another large randomized trial such as the complete versus culprit - lesion only primary pci trial ( cvlprit ) may provide more valuable information.26 ) these stemi studies are summarized in table 1 .
culprit vessel - only revascularization is an interventional strategy that revascularizes only the ira during primary pci , regardless of the significance of non - iras .
thus , it is a conservative management approach that allows for revascularization of the ira only followed by medical therapy , and some studies have shown more favorable outcomes of cvr than mvr during primary pci .
an early study by roe et al.10 ) described increased 6-month mortality and major adverse cardiac events ( maces ) with mvr .
corpus et al.5 ) analyzed 506 patients with mvd ; 152 were treated with mvr and 354 were treated with cvr during primary pci .
mvr was associated with higher rates or re - infarction ( 13.0% vs. 2.8% , p<0.001 ) , revascularization ( 25.0% vs. 15.0% , p=0.007 ) , and composite mace ( 40.0% vs. 28.0% , p=0.006 ) compared to cvr after 1-year of clinical follow - up .
a recent analysis of the apex - ami trial11 ) examined the incidence of cvr during primary pci and 90-day outcomes compared to mvr . among 2210 patients with mvd , only 217 ( 9.9% ) underwent cvr .
death and death / congestive heart failure / shock after 90-days was significantly higher in the mvr group than that in the cvr group ( 12.5% vs. 5.6% , p<0.001 and 17.4% vs. 12.0% , p=0.020 , respectively ) .
furthermore , mvr was associated with an increased risk of 90-day mortality { adjusted hazard ratio ( hr ) 2.44 ; 95% confidence interval ( ci ) , 1.55 - 3.83 ; p<0.001 } after adjusting for patient and procedural characteristics , as well as the propensity for mvr .
dziewierz et al.12 ) reported that non - ira pci during an index procedure in patients with stemi and mvd is associated with increased 1-year mortality in a registry database ( european registry on patients with st - elevation mi transferred for mechanical reperfusion with a special focus on upstream use of abciximab ; eurotransfer ) .
recent studies also showed inferior clinical outcomes of mvr compared to patients who received cvr during primary pci,13)14 ) and the meta - analysis of vlaar et al.15 ) revealed higher mortality rates of patients who underwent mvr during long - term follow - up compared to cvr or a staged pci group .
limited data show the benefits of simultaneous ira and non - ira intervention during primary pci .
although several early studies supported the superiority of mvr over cvr , they included only a small number of patients and were not randomized.16)17)18 ) politi et al.19 ) performed a randomized trial assessing the outcomes of 214 patients with stemi and mvd undergoing primary pci .
all patients were randomized before angioplasty into cvr , ad hoc mvr , and staged pci groups . during a mean follow - up of 2.5 years
, there were more maces in the cvr group ( 50% of patients ) than those in the mvr ( 23% ) and staged pci ( 20% ) groups .
bangalore et al.20 ) performed a meta - analysis of 61764 subjects with stemi and mvd in 19 studies with 23 arms , and associated mvr with a 44% decrease in repeat pci and maces { odds ratio ( or ) , 0.68 ; 95% ci , 0.57 - 0.81 } for early outcomes within 30 days , despite similar mortality , mi , stroke , and target vessel revascularization .
no differences related to mi , target vessel revascularization , or stent thrombosis were observed for long - term outcomes , with a decreased risk of mortality , repeat pci , coronary artery bypass surgery , and mace ( or , 0.60 ; 95% ci , 0.50 - 0.72 ) with mvr .
however , that study was limited because it was a non - randomized trial that included only two randomized controlled trials in the meta - analysis . a recent trial by wald et al.21 ) randomized 465 patients with stemi who underwent primary pci into two groups : preventive pci ( 234 patients ) or no preventive pci ( 231 patients ) .
primary outcomes were composite cardiac deaths , non - fatal mi , and refractory angina . during a mean follow - up of 23 months , primary outcomes occurred more often in the no preventive pci group ( hr , 0.35 ; p<0.001 ) and the hrs were 0.34 for cardiac death , 0.32 for non - fatal mi , and 0.35 for refractory angina .
they concluded that preventive pci in non - ira significantly reduced the risk of mace compared to cvr in patients with stemi who underwent primary pci . in a large - scale korean registry ( korea acute myocardial infarction registry , kamir )
, two recent studies evaluated the efficacy of mvr in patients with stemi and mvd.22)23 ) jo et al.22 ) analyzed 1094 stemi patients with mvd who underwent primary pci with drug - eluting stents ( 827 in the cvr and 267 in the mvr groups ) . during a 1-year follow - up , mace rates were similar in the cvr ( 15.2% ) and mvr ( 14.2% ) groups , despite higher in - hospital mortality in the cvr group ( 5.2% vs. 0.4% , p<0.001 ) . in subgroup analyses between complete ( n=182 ) and incomplete ( n=912 ) revascularized patients , the former had a lower 1-year mace rate ( 9.5% vs. 15.0% , p=0.039 ) primarily driven by the non - target vessel repeat pci rate ( 1.8% vs. 8.6% , p=0.002 ) .
however , complete revascularization was associated with a lower rate of non - target vessel repeat revascularization during the follow - up period after multivessel pci in subgroup analyses .
lee et al.23 ) also compared cvr ( 1106 patients ) with mvr ( 538 patients ) in 1644 stemi and mvd patients who received primary pci using stent implantation or balloon angioplasty .
inhospital outcomes such as mortality , complications , acute kidney injury , major bleeding , and new onset heart failure were similar between the two groups , except for the development of fatal ventricular arrhythmia ( 4.5% vs. 2.4% , p=0.037 ) . at 1 month , the occurrence of mace was not different between the two groups .
the mace rate at 1 year was also similar between both groups ; however , the target - lesion repeat pci rate was higher in the mvr group ( 2.4% vs. 5.9% , p<0.0001 ) .
therefore , they concluded that there were no significant differences in clinical outcomes between the groups , except for a higher risk of target lesion revascularization in the mvr group .
these two kamir studies showed similar results in that mvr was not superior to cvr in patients with stemi and mvd .
however , the 1-year repeat target - lesion pci rate was higher in the mvr group in the latter study , which might be associated with a higher proportion of bare - metal stents implanted in the study population ( 8.7% in the cvr group and 11.0% in the mvr group ) , as well as other angiographic factors .
however , limited information on staged pci and a lack of detailed angiographic anatomies in these studies may have underestimated the outcomes .
although some studies have shown superiority of mvr in patients with stemi , the results have been limited by changes in standard interventional strategies of primary pci .
although there is no definitive evidence that mvr is superior to cvr , and the current guidelines support cvr during primary pci , several recent studies have suggested that staged multivessel pci can be an alternative interventional strategy to achieve optimal clinical outcomes .
hannan et al.13 ) showed that culprit vessel pci during the index procedure for patients without hemodynamic compromise is associated with lower in - hospital mortality than multivessel pci during the index procedure ( 0.9% vs. 2.4% , p=0.04 ) .
interestingly , patients who underwent staged multivessel pci within 60 days after the index procedure had a significantly lower 12-month mortality rate than those who underwent culprit vessel pci only ( 1.3% vs. 3.3% , p=0.04 ) .
vlaar et al.15 ) performed a meta - analysis including four prospective and 14 retrospective studies involving 40280 patients .
their analysis favored a staged pci strategy with complete revascularization . among different interventional strategy groups , staged pci was associated with lower short- and long - term mortality compared to cvr and ad hoc mvr , and the mvr group showed the highest mortality rates at both short- and long - term follow - ups .
another study supported the use of staged pci . a subgroup analysis in the harmonizing outcomes with revascularization and stents in acute myocardial infarction trial ( horizons - ami)24 ) compared cvr to staged pci ;
the results indicated higher 1-year mortality ( 9.2% vs. 2.3% ; hr , 4.10 ) , cardiac death ( 6.2% vs. 2.0% ; hr , 3.14 ) , and stent thrombosis ( 5.7% vs. 2.3% ; hr , 2.49 ) in the cvr group than those in the staged pci group .
furthermore , there was a trend toward higher 1-year adverse cardiac events ( 18.1% vs. 13.4% ; hr 1.42 ; p=0.08 ) in the former group . jensen et al.25 ) also reported that staged multivessel pci within 60 days after index hospitalization can reduce 1-year mortality compared to patients who undergo cvr during primary pci ( hr , 0.28 ; 95% ci , 0.14 - 0.54 ) .
taken together , these results indicate that staged pci is promising , and another large randomized trial such as the complete versus culprit - lesion only primary pci trial ( cvlprit ) may provide more valuable information.26 ) these stemi studies are summarized in table 1 .
although current guidelines recommend cvr during primary pci in patients with stemi , mvr can be selected when stemi patients initially present in cardiogenic shock that is primarily associated with stemi .
thus , studies regarding mvd and shock with ami have reported this issue in stemi patients.27 ) several studies of mvr in stemi patients complicated by cardiogenic shock have demonstrated no additional benefit of mvr in this circumstance .
cavender et al.14 ) analyzed patients with stemi and cardiogenic shock in the national cardiovascular data registry ( n=3087 ) and showed that those who received mvr during primary pci had greater in - hospital mortality than that of patients that received cvr ( 36.5% vs. 27.8% ; or , 1.54 ; 95% ci , 1.22 - 1.95 ) .
these data suggest that performing mvr during primary pci for stemi does not improve short - term survival , even for patients with cardiogenic shock and at - risk for increased mortality due to procedural - related complications , such as bleeding or renal failure , distal embolization associated with pci , or the loss of collateral flow to other coronary territories.28)29 ) bauer et al.30 ) evaluated the impact of mvr on in - hospital outcomes of 336 ami patients with mvd presenting with cardiogenic shock in the euro heart survey pci registry .
the prevalence of three - vessel disease ( 60% vs. 57% ) , presentation with resuscitation ( 48% vs. 46% ) , and stemi ( 83% vs. 87% ) were similar between the two patient groups who received another interventional strategy when mvr and cvr were compared . after adjusting for confounding factors ,
an additional non - culprit pci was not associated with an in - hospital survival benefit ( or , 1.28 , 95% ci , 0.72 - 2.28 , p=0.07 ) in these high - risk patients . in a recent korean study , yang et al.31 )
reported that mvr did not reduce the prevalence of mortality in patients with cardiogenic shock complicating stemi and mvd during primary pci . a recent french study on the role of mvr in patients with stemi presenting with cardiogenic shock and resuscitated cardiac arrest showed that mvr may improve 6-month survival rate.32 ) however
, these results can not be generalized until results are reported from a randomized controlled trial .
current 2010 esc / eacts myocardial revascularization guidelines state that mvr during primary pci can be justified only in hemodynamically unstable patients with multiple truly critical lesions,33 ) and this interventional strategy is still an effective modality in these patients .
the results described above are heterogeneous and thus inconclusive regarding applications in real - world practice .
multivessel pci has advantages and disadvantages , as described by widimsky and holmes ( table 2).7 ) the following factors should be considered before determining the interventional strategy .
first , in patients with stemi and mvd , cvr is still an effective interventional strategy during primary pci in hemodynamically stable patients , as recommended by the current guidelines . a recent meta - analysis by bagai et al.34 ) analyzed outcomes of mvr compared to cvr during primary pci in 14 studies composed of 11 cohort and three randomized controlled trials .
the mvr group had more patients in cardiogenic shock and with an anterior infarction . although short- and long - term mace occurred more often in the mvr group , the primary endpoint was similar after excluding patients with shock in analyses limited to randomized controlled trials .
another small study reported similar results and risk profiles of patients undergoing mvr during primary pci.35 ) because there may be selection bias in non - randomized trials that compare mvr and cvr , more randomized controlled trials are needed to confirm these conclusions .
second , cvr is also an effective interventional strategy during primary pci in patients with hemodynamically unstable stemi .
several studies that compared mvr to cvr during primary pci in patients in cardiogenic shock did not demonstrate any advantage to mvr .
one prospective observational study described that mvr primary pci in stemi patients with mvd presenting with cardiogenic shock and resuscitated cardiac arrest improved short - term mortality.32 ) mvr during primary pci in patients with stemi and mvd should be selected in patients in a hemodynamically unstable state with multiple critical coronary stenoses .
third , staged pci is highly recommended in patients who receive cvr during primary pci .
several reports and a recent randomized controlled trial have shown promising results with this strategy .
however , it remains to be determined whether complete or incomplete revascularization , non - ira intervention , and timing of intervention can be improved .
although recent studies have supported complete revascularization in patients , including those with angina,36)37)38 ) more studies are needed to establish staged pci in these patients . however , different clinical scenarios in a real - world setting cause hardship when applying these literature - based interventional strategies .
dangas et al.39 ) surveyed this issue based on the opinions of interventional cardiology experts .
about 80% of interventional cardiologists are consistent in their recommendation to elect second staged pci in case of stemi patients with mvd with a concurrent significant proximal lesion in a nonculprit vessel who are hemodynamically stable after primary pci .
many factors such as renal function , accumulated contrast use , lesion complexity , symptomatology , radiation dose , left ventricular function , insurance status , and patient age influenced their decisions .
the decision making for pci in patients with stemi and mvd should be individualized according to the clinical situation .
there are several considerations that need to be made prior to non - ira intervention to assist decision making for multivessel pci .
the adequacy of the intervention should be compared to coronary artery bypass graft ( cabg ) surgery based on clinical benefits in patients with mvd .
the current acc / aha guidelines recommend cabg ( class i indication , level of evidence : a ) in patients with mvd according to the complexity of the coronary anatomy , such as three - vessel disease or left main coronary artery disease or two - vessel disease with significant proximal left anterior descending coronary artery disease and abnormal left ventricular dysfunction .
however , it is difficult to recommend cabg based on the guidelines in all patients indicated for surgery because of advanced age , co - morbidities , and the high complication rate of cabg .
the " synergy between pci with taxus and cardiac surgery " ( syntax ) score was designed to predict outcomes related to anatomical characteristics such as the dominant artery , number of lesions , other lesion characteristics , and , to a lesser extent , the functional risk of occlusion of any coronary artery segment in patients with mvd.40 ) a high syntax score indicates the most complex disease . in the syntax trial,41 ) patients with a high syntax score ( > 33 points ) who underwent pci showed poorer cardiovascular outcomes compared to those who underwent cabg .
although this scoring system can not be applied to all patients with mvd , it may be helpful for determining whether pci or surgery is better in individual patients .
a functional assessment of myocardial viability is also crucial for reducing unnecessary revascularization of non - ira .
dobutamine echocardiography42 ) and myocardial nuclear imaging , such as single photon emission tomography or positron emission tomography,43 ) are well - known modalities used to evaluate myocardial viability .
cardiac magnetic resonance imaging ( cmri ) has increasingly been performed to accurately predict infarct size , regional wall motion abnormalities , ejection fraction , and myocardial irreversibility.44)45 ) in addition , cmri can predict functional recovery of the left ventricle after pci.46 ) however , because there are no available data on the clinical benefits of cmri - guided intervention for assessing the significance of non - ira , the fractional flow reserve ( ffr ) procedure is practical for determining the level of ischemia using a pressure wire .
the fractional flow reserve versus angiograph for multivessel evaluation ( fame ) study was a randomized , prospective , multicenter trial that investigated the benefits of ffr - guided pci .
this technique was associated with lesser stent implantation , less injection of contrast , and a reduction in adverse cardiac events , death , or myocardial infarction.47)48)49 ) this remarkable result supports the active use of ffr for assessing ischemia during intermediate coronary stenosis .
based on the current literature , the optimal revascularization strategy for stemi patients with mvd remains controversial .
assessment of myocardial viability and a functional evaluation of myocardial perfusion are essential before non - ira intervention .
current guidelines supporting cvr during primary pci as a default strategy may impact initial management , and ad hoc pci should be carefully performed only in hemodynamically unstable patients .
promising results for staged pci in stemi patients with mvd suggest that this strategy should be considered before other methods .
thus , individualization of treatments and a consideration of the advantages or disadvantages of the intervention remain important . further large - scale , randomized ,
controlled trials are necessary to establish the optimal revascularization strategy for these high - risk patients .
 primary percutaneous coronary intervention ( pci ) is a standard interventional treatment modality for st - segment elevation myocardial infarction ( stemi ) . 
 diagnostic coronary angiogram during pci reveals multivessel coronary artery disease in about half of patients with stemi , and it is difficult to make decision on the extent of intervention in these patients . 
 although revascularization for the infarct - related artery only is still effective for stemi patients , several studies have reported the efficacy of multivessel revascularization during primary pci , as well as in a staged pci procedure . 
 clinicians should consider clinical aspects such as initial cardiogenic shock and myocardial viability when performing primary multivessel intervention , including the risks and benefits of multivessel revascularization in patients undergoing primary pci . 
 this review describes the current status of performing multivessel pci in patients with stemi and proposes an optimal revascularization strategy based on the previous literature . 
Introduction
Interventional Strategies for ST-Segment Elevation Myocardial Infarction with Multivessel Coronary Artery Disease
Infarct-related artery intervention during primary percutaneous coronary intervention
Simultaneous infarct-related and non infarct-related artery intervention during primary percutaneous coronary intervention
Staged percutaneous coronary intervention: infarct-related artery intervention followed by non-infarct-related intervention as a staged procedure
Optimal Interventional Strategy in Patients with Multivessel Coronary Artery Disease Complicating Cardiogenic Shock
Real-World Application of Multivessel Intervention in Patients with ST-Segment Elevation Myocardial Infarction
Conclusions