Which One Should be Treated in the Setting of Acute ST Elevation Myocardial Infarction - Culprit Lesion or Culprit Vessel?

Patient selection: This multi-centre retrospective study included patients from 3 high-volume primary PCI centres in Turkey. A total number of 5512 patients underwent emergent PCI for acute STEMI between January 2011 and December 2013. From this patient population, patients were looked for the presence of an additional lesion to the culprit lesion (CL). Additional lesion was defined as the presence of an angiographically severe (≥70%) lesion other than the CL either proximal or distal to it in the same coronary artery after the distal flow was observed most commonly as a result of guide-wire passage or PTCA of the total occlusion.

Exclusion criteria: - Presence of LMCA lesion

• Cardiogenic shock
• Previous CABG operation
• Decision for CABG operation after primary PCI
• Severe valvular disease including aortic stenosis of mitral insufficiency
• Severe kidney disease (serum creatinine >2.5 mg/dl or patients on maintenance hemodialysis)
• Rejection of second PCI by the patient after the index event

The eligible patients were retrospectively sought from the database of the relevant hospital. The basal characteristics of the patients like age, sex, presence of coronary risk factors (smoking, hypertension, diabetes mellitus and hyperlipidemia), vital signs and location of STEMI at admission were noted. The emergent coronary angiograms of the patients were then examined and several angiographic and post-PCI features which are defined in detail in the following sections were addressed. Follow-up of these patients were succeeded either by phone call, routine polyclinic visits or from the database of hospital.

Study groups: Patients were grouped into 2 according to the PCI strategy; culprit vessel (CV) group including patients who underwent emergent PCI of all severe (≥70 stenosis in CAG) lesions in the culprit vessel and culprit lesion (CL) group including patients who underwent emergency PCI only for the CL and staged PCI in 2 weeks for the other additional lesions in the CV. Both groups underwent staged PCI for the severe lesion(s) in non-culprit vessel(s) if necessary in a different session in 28 days after the index event. Staged PCI was the preferred strategy in both groups if necessary because staged PCI has been found to be at least non-inferior to other strategies in several studies [3, 4, 10, 13].