ABC | Volume 115, Nº2, August 2020

Short Editorial de Souza e Silva Complete vs. culprit-lesion-only revascularization Arq Bras Cardiol. 2020; 115(2):238-240 in mortality was no longer significant after adjustment for potential covariates. In contrast, Dimitriu-Leen et al. 10 found that the mortality rate at 1 year of follow-up was significantly higher for patients who were treated with incomplete revascularization compared with patients who underwent complete revascularization (9.8% vs 4.3%, respectively, p=0.02). However, after performing multivariate Cox regression analysis, incomplete revascularization was not independently associated with increased all-cause mortality. In view of the results presented above, could we draw the conclusion that patients presenting with STEMI and multivessel CAD should undergo complete revascularization? Before answering this question, some issues found in the studies addressing this topic should be underscored. First, there is a great heterogeneity in the adopted protocols between both RCT and observational studies that compare complete revascularization vs. culprit-lesion-only PCI, mostly regarding to the timing of nonculprit lesion PCI - during the index PCI procedure or as staged revascularization, and the criteria used to define significant stenosis - 50% or 70% visually determined or guided by fractional flow reserve measurement, which hampers the comparability between the reported results. Second, especially regarding to RCT, it should be taken into account the possibility of publication bias, when studies with statistically significant results have increased likelihood of being published, in this case, favoring complete revascularization. Third, particularly regarding to the published article in this issue of the Arquivos Brasileiros de Cardiologia journal, small sample studies are of greater risk of certain types of bias that can significantly alter their findings favoring one or another strategy, and, thus, larger observational studies are further needed to confirm Cadore et al. 7 findings. Moreover, although few studies have shown differences in hard outcomes such as myocardial infarction and cardiovascular death favoring complete revascularization, the majority does not show any difference in all-cause mortality, which might suggest that other causes of death potentially associated with PCI procedures, such as infection, might not have been considered. Finally, whether to treat nonculprit lesions with PCI in STEMI could be discussed in a larger context, based on the impact of stenting stable lesions. Recent evidence provided by the ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) trial 11 showed that among patients with stable coronary disease who had moderate or severe ischemia, an initial invasive strategy, as compared with an initial conservative strategy, did not reduce the rates of the primary composite outcome death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. Therefore, although patients and clinicians are often more comfortable with revascularization of all suitable coronary stenosis rather than medical therapy, more data from both RCT and observational studies is needed to evaluate if complete revascularization provides additional benefit over culprit- lesion-only PCI in patients with STEMI and multivessel CAD. For now, a reasonable approach should incorporate clinical judgment, and any benefit of revascularization of lesions in nonculprit arteries should be counterbalanced by potential disadvantages of additional PCI procedures. 1. Park DW, Clare RM, Schulte PJ, Pieper KS, Shaw LK, Califf RM, et al . Extent, location, and clinical significance of non-infarct-related coronary artery disease among patients with ST-elevation myocardial infarction. JAMA. 2014;312(19):2019-27. 2. Wald DS, Morris JK, Wald NJ, Chase AJ, Edwards RJ, Hughes LO, et al . Randomized trial of preventive angioplasty inmyocardial infarction. N Engl J Med. 2013;369(12):1115-23. 3. EngstrømT, Kelbæk H, Helqvist S, Høfsten DE, Kløvgaard L, Holmvang L, et al . Complete revascularisation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multivessel disease (DANAMI-3—PRIMULTI): an open-label, randomised controlled trial. Lancet. 2015;386(9994):665-71. 4. Gershlick AH, Khan JN, Kelly DJ, Greenwood JP, Sasikaran T, Curzen N, et al . Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multives seldisease:theCvLPRITtrial.JAmCollCardiol .2015;65(10):963-72. 5. Mehta SR, Wood DA, Storey RF, Mehran R, Bainey KR, Nguyen H, et al . Complete RevascularizationwithMultivessel PCI for Myocardial Infarction. N Engl J Med. 2019;381(15):1411-21. 6. Bainey KR, Engstrøm T, Smits PC, Gershlick AH, James SK, Storey RF, et al . Complete vs Culprit-Lesion-Only Revascularization for ST-Segment Elevation Myocardial Infarction: A Systematic Review and Meta- analysis. JAMA Cardiol. 2020. 7. Cadore JC, FurtadoMV, Tumelero R, Tognon A, Krepsky AM, CadoreD, et al. Complete Revascularization Versus Treatment of the Culprit Artery Only in ST ElevationMyocardial Infarction: AMulticenter Registry. Arq Bras Cardiol. 2020; 115(2):229-237). 8. Cavender MA, Milford-Beland S, Roe MT, Peterson ED, Weintraub WS, Rao SV. Prevalence, predictors, and in-hospital outcomes of non-infarct artery intervention during primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (from the National Cardiovascular Data Registry). Am J Cardiol. 2009;104(4):507-13. 9. Dziewierz A, Siudak Z, Rakowski T, Zasada W, Dubiel JS, Dudek D. Impact of multivessel coronary artery disease and noninfarct-related artery revascularization on outcome of patients with ST-elevation myocardial infarction transferred for primary percutaneous coronary intervention (from the EUROTRANSFER Registry). Am J Cardiol. 2010;106(3):342-7. 10. Dimitriu-Leen AC, Hermans MP, Veltman CE, van der Hoeven BL, van Rosendael AR, van Zwet EW, et al . Prognosis of complete versus incomplete revascularisation of patients with STEMI with multivessel coronary artery disease: an observational study. Open Heart. 2017;4(1):e000541. 11. 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