Treating patients with non-STEMI: stent the culprit artery only or address all lesions?

Non-ST segment elevation myocardial infarction (non-STEMI) is a common presentation of the acute coronary syndrome (ACS) spectrum. Currently, the recommended treatment option is an invasive approach with angiography plus coronary revascularization to treat the culprit lesion. However, unlike in STEMI--in which the culprit lesion can be easily identified--in non-STEMI identifying the culprit lesion is difficult. Therefore, some have advocated for a more definitive approach to addressing all severe lesions in patients presenting with non-STEMI. The current European guidelines for percutaneous coronary intervention (PCI) for multivessel versus culprit-only stenting state that "the decision to perform either culprit vessel or complete revascularization can be made on an individual basis," whereas the American College of Cardiology/American Heart Association guidelines for multivessel PCI in patients presenting with ACS recommend that "it be performed when there is a high likelihood of success and a low risk of morbidity and the vessels to be dilated subtend a moderate or large area of viable myocardium and have high risk by noninvasive testing." Although lesions and coronary anatomies are each unique and the risk and benefit of coronary intervention to each lesion should be carefully examined, we recommend stenting the culprit lesion and other severe lesions after careful consideration, in a staged fashion if necessary. If the severity of nonculprit lesions is in question, fractional flow reserve or intravascular ultrasound should be considered.