ABC | Volume 115, Nº2, August 2020

Original Article Cadore et al. Preventive Angioplasty in Myocardial Infarction Arq Bras Cardiol. 2020; 115(2):229-237 Although the benefit of a staged strategy following primary PCI has been suggested in several studies including this one, questions remain to be elucidated, such as appropriate timing for staged PCI. In clinical practice, factors such as renal dysfunction, lesion complexity, contrast volume, radiation dose, hemodynamic status, and patient status may influence the decision on optimal timing for revascularization. An electronic survey conducted by the ACC revealed that, although most interventional cardiologists agree to perform CR with a staged approach, their opinions regarding optimal timing for the second PCI vary greatly. Only 22% of respondents performed both first and second interventions at the same hospitalization; most cardiologists recommended waiting at least 15 days for the second procedure. 23 Despite the evidence and ongoing studies, no study may be able to define a single strategy for patients with STEMI and multivessel CAD. As these patients are heterogeneous, the strategy must be individualized. Undoubtedly, the focus should be on treating the culprit lesion. The decision should ideally be made by a heart team taking anatomical complexity, ventricular function, and patient profile into account in order to reach the best strategy. A complete risk stratification with clinical and angiographic data is crucial for evaluating the patients properly. 24 The present study has some limitations that should be considered, especially those related to its observational nature. The chance of selection bias cannot be excluded, even though no statistically significant differences were identified regarding the study variables related to the baseline characteristics of patients treated with CR or IR. Also, no change was found in the effect of the strategy on the occurrence of primary outcome due to the factors considered in multivariable analysis, as the intervention strategy was at the operator’s discretion. Moreover, this study included a small number of patients from two centers in southern Brazil and may not be representative of settings in other regions and non-public services. Figure 1 – Twelve-month survival after complete revascularization (CR) and incomplete revascularization (IR) in patients with acute ST-segment elevation myocardial infarction (STEMI) and multivessel disease. *Log-rank test. Cumulative survival Follow-up time (months) 1.0 0.8 0.6 0.4 0.2 0.0 0 3 6 12 9 Revascularization Complete Incomplete Censoring Censoring 234