Page 171 - Coronary hemodynamics in acute myocardial infarction - Matthijs Bax

Coronary flow unequivocally plays a dominant role in cardiac function, and thus, routine coronary flow or flow velocity assessment is a prerequisite for our insight into the hemodynamics of coronary syndromes. Although the development of coronary flow velocity techniques stagnated over the past years, recent research in the field of coronary flow velocity and flow velocity reserve led to a novel understanding of the macro and microcirculatory involvement in ischemic heart disease,1, 2 and has reinvigorated interest in coronary flow (velocity) technology.
Over the years, knowledge about the abnormal values of the baseline and hyperemic blood flow velocity in non-IRA following a heart attack has become of paramount importance.
Recently, studies have been conducted in which STEMI patients treated with PPCI underwent additional PCI of their non-culprit multivessel lesions remote of the infarcted area. The question if multivessel PCI is indicated at the time of myocardial infarction is of clinical relevance since multivessel disease exists in half of the patients admitted with STEMI. Studies comparing culprit vessel- only with multivessel PCI have reported conflicting results3-11 Previous clinical practice guidelines recommended culprit-only strategy PCI in STEMI patients. In 2015 however, the prior Class III (harm) recommendation was upgraded to a Class IIb recommendation (level of evidence B-R) to consider multivessel PCI in stable STEMI patients, either at the time of PPCI or as a planned, staged procedure.12 Interestingly, the most recent, randomized studies demonstrate the benefit of multi-vessel PCI treatment at the time of PPCI as well as a staged procedure.
Since it is known that the angiographic severity of the stenosis does not indicate its functional significance in patients with stable coronary artery disease, it is conceivable that physiological measurements of non-culprit lesions may be used to determine the need for adjunctive or preventive PCI in the context of a STEMI. Determining the severity of the non-culprit stenosis was done by FFR measurement in several studies.8, 10, 11 In the recently published COMPLETE study, comparing complete revascularization during or after the index hospitalization versus conservative medical treatment, the randomization was done after eyeballing of the severity of the non-culprit lesions. If the lesion severity was 50-
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General discussion and future perspectives
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