Guideline For Percutaneous Coronary Intervention Research Articles

Percutaneous coronary intervention of unprotected left main coronary artery disease

Data have emerged demonstrating the safety and efficacy of percutaneous coronary intervention (PCI) of the unprotected left main (ULM) artery. The 2009 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions focused guidelines for PCI no longer state that ULM PCI is contraindicated in patients with anatomic conditions that are associated with a low risk of procedural complications and clinical conditions that predict an increased risk of adverse surgical outcomes. ULM PCI should be performed by operators with experience in the management of the anatomic complexities of left main and multivessel disease, specifically in issues relating to bifurcation disease, calcification, and hemodynamic support. Patients with ostial or shaft disease have lower risk of restenosis compared with distal bifurcation disease. Drug-eluting stents (DES) should be used whenever possible as they reduce clinical restenosis. Intravascular ultrasound is an integral component of the procedure as it provides accurate assessment of lesion severity and can confirm optimal stent expansion and apposition. Compliance with dual antiplatelet therapy for at least 12 months is essential if DES are used. A collaborative, multidisciplinary approach with a "Heart Team" represented by a cardiac surgeon, interventional cardiologist, and non-invasive cardiologist may optimize patient education and objective decision making when obtaining informed consent. Application of clinical and angiographic variables into risk models facilitates appropriate patient selection. Randomized clinical trials will address unanswered issues and help build consensus between cardiology and surgical societies to inform clinical decision making and optimize the outcomes for patients with ULM coronary artery disease.

In-stent restenosis: the gold standard has changed

In-stent restenosis remains an important issue even in the drug-eluting stent (DES) era today. In recent years, drug-eluting balloons (DEB) have emerged as a potential alternative to the treatment of in-stent restenosis. Paclitaxel was identified as the primary drug for DEB because of its rapid uptake and prolonged retention. Non-stent-based local drug delivery using DEB maintains the antiproliferation properties of DES, but without the limitations of DES such as subacute stent thrombosis, stent fractures, prolonged antiplatelet therapy and more importantly, avoiding a "stent-in-a-stent" approach. The first major impact of drug-eluting balloon (DEB) in the management of bare metal instent restenosis was the "PACCOCATH ISR I" randomised trial, comparing the efficacy of drug-eluting balloon versus uncoated balloon. The six months angiographic results showed a binary restenosis of 5% and 4% MACE in the drug-eluting balloon group, compared with 43% binary restenosis and 31% MACE, in the uncoated balloon group (p=0.002 and 0.02). The second major DEB trial is the "PEPCAD II Trial", comparing the efficacy of the SeQuent Please DEB with the Taxus drug-eluting stent in the treatment of bare-metal stent instent restenosis. At 6-month follow-up, in-segment late lumen loss was 0.38 ± 0.61 mm in the DES group versus 0.17 ± 0.42 mm (p=0.03) in the DEB group, resulting in a binary restenosis rate of 12/59 (20%) versus 4/57 (7%; p=0.06). At 12 months, MACE rates were 22% in the Taxus group and 9% in the DEB group (P=0.08). The TLR at 12 months was 15% in the Taxus group and 6% in the DEB group (p=0.15). Based on these two pivotal trials, the European Society of Cardiology Guidelines for Percutaneous Coronary Intervention (2010) recommended that DEB should be considered for the treatment of in-stent restenosis after prior bare-metal stent. This was accorded a class 2 IIa indication, with a level B evidence.

Optimal Use of Thienopyridines in Non-ST-Elevation Acute Coronary Syndrome Following CURRENT-OASIS 7

Over the past decades, antiplatelet therapy has evolved from the relatively weak oral agent aspirin to additional oral and parenteral agents with greater antiplatelet activity. One example of a successful agent is the second-generation thienopyridine clopidogrel. Clopidogrel inhibits platelet P2Y12 receptors and given with aspirin, which inhibits cyclooxygenase-1 enzyme, composes the actual standard of care of dual antiplatelet therapy.1–3 Dual antiplatelet therapy is recommended by the American College of Cardiology/American Heart Association, American College of Chest Physicians, and the European Society of Cardiology (ESC) for patients undergoing percutaneous coronary intervention (PCI) and patients with ST-elevated myocardial infarction (STEMI) or unstable angina (UA)/non-STEMI (NSTEMI).4–10 A common point of emphasis in these guidelines is the recommendation to provide a clopidogrel loading dose (LD) before PCI, although uncertainty remains in these recommendations on the optimal dose and optimal timing of administration. Whereas the American College of Cardiology/American Heart Association UA/NSTEMI guidelines recommend a 300-mg clopidogrel LD, they acknowledge that although the supporting evidence is much weaker than that for a 300-mg LD, a higher dose of 600 or 900 mg may be more beneficial in some circumstances.8 The PCI guidelines recommend a 600-mg clopidogrel LD before or during the procedure.10 The ESC guidelines suggest that a 600-mg LD may be initiated immediately after the first medical contact for invasively managed patients with NSTEMI.5,6 Unfortunately, there are no clinical data and, therefore, no recommendation on the maintenance dose (MD) during the acute phase or chronic phase. The Clopidogrel Optimal Loading Dose Usage to Reduce Recurrent Events/Optimal Antiplatelet Strategy for Interventions (CURRENT-OASIS 7) trial is the first large-scale, randomized trial to compare 2 strategies: high-dose clopidogrel (600-mg LD/150-mg MD) versus standard-dose clopidogrel (300-mg LD/75-mg MD) to assess the added benefit of a higher platelet …

The optimal pharmacological formula for percutaneous coronary intervention

Introduction: Adjunctive pharmacotherapy is of key importance in determining the outcomes of percutaneous coronary intervention (PCI). In parallel, there has been an increasing body of evidence indicating that the aggressive management of coronary risk factors and changes in lifestyle behavior yield additional positive results in morbidity and mortality reductions. A stream of new data from randomized clinical trials has recently prompted the release of a focused update of the PCI guidelines, endorsing new recommendations on the use of antiplatelet drugs and parenteral anticoagulants.Areas covered: The aim of this manuscript is to provide an up-to-date overview of the current evidence on the use of adjunctive pharmacological therapy in patients undergoing revascularization, with focus on results of recent trials and future directions.Expert opinion: Given the availability of several pharmacological agents with different mechanisms of action, understanding whether a drug should or should not be prescribed, as well as individualizing the pharmacological formula to the patient's need and risk category, is pivotal to balance the safety and efficacy of adjunctive therapies for PCI. Studies on new antiplatelet agents and selective inhibitors of specific coagulation factors are likely to characterize the next years of research on interventional pharmacology.

Adherence of Catheterization Laboratory Cardiologists to American College of Cardiology/American Heart Association Guidelines for Percutaneous Coronary Interventions and Coronary Artery Bypass Graft Surgery: What Happens in Actual Practice?

Adherence of Catheterization Laboratory Cardiologists to American College of Cardiology/American Heart Association Guidelines for Percutaneous Coronary Interventions and Coronary Artery Bypass Graft Surgery: What Happens in Actual Practice?

Safety and Efficacy of Prolonged Use of Unfractionated Heparin After Percutaneous Coronary Intervention

The current guidelines for percutaneous coronary intervention do not address the prolonged postprocedural use of unfractionated heparin (UFH) to prevent acute occlusion. However, recently published small studies have yielded mixed results, leaving the question unanswered. Hence, we performed a meta-analysis of the existing evidence to assess the safety and efficacy of prolonged infusion of UFH after percutaneous coronary intervention. A systematic review of literature revealed seven studies involving 2412 patients. End points analyzed were ischemic complications (acute closure, myocardial infarction, and repeat revascularization) and major vascular complications (hematoma, arteriovenous fistula, pseudoaneurysm, and retroperitoneal bleed). Because the studies were homogenous for outcomes, combined relative risks across all the studies and the 95% confidence intervals were computed using the Mantel-Haenszel fixed-effect model. A two-sided alpha error <0.05 was considered to be statistically significant. There were no significant differences in patient demographics between both groups. Compared with placebo, the risk of major vascular complication was significantly higher in patients getting postprocedural UFH for prolonged hours (relative risk, 2.24; confidence interval, 1.68-3.48; P = 0.001). However, the risk of ischemic complications was similar in both groups (relative risk, 0.95; confidence interval, 0.46-1.96; P = 0.89). The meta-analysis suggests that routine infusion of UFH after uncomplicated percutaneous coronary intervention may result in increased vascular complications without any reduction in incidence of ischemic complications.

Impact of Changes in Clinical Practice Guidelines on Assessment of Quality of Care

Measures for pay-for-performance and public reporting programs may be based on clinical practice guidelines. The impact of guideline changes over time-and whether evolving clinical evidence can render measures based on prior guidelines misleading-is not known. To assess the impact of using different percutaneous coronary intervention (PCI) guidelines when evaluating whether PCI was indicated. PCIs from the National Cardiovascular Data Registry's CathPCI registry performed in 2003-2004 were categorized into indication classes (Class I, IIa, IIb, III), using 2001 American College of Cardiology/American Heart Association guidelines for PCI, the guidelines available at the time of the procedures. The same procedures were recategorized using 2005 guidelines, which reflect the best evidence available to clinicians at the time of PCI. Procedures unable to be categorized were labeled as "Not Certain." Patients undergoing PCI for stable or unstable angina in 394 hospitals. Number of procedures changing classification categories using 2001 versus 2005 guidelines. A total of 345,779 PCIs were evaluated. Applying 2001 guidelines, 47.9% had Class I indications; 33.3% Class IIa; 5.9% Class IIb; 3.7% Class III; and 9.2% Not Certain. Applying 2005 guidelines to the same procedures, 25.1% had Class I indications; 57.5% Class IIa; 5.5% Class IIb; 3.7% Class III; and 8.3% Not Certain; 41.1% of procedures changed the classification overall. The changes in guidelines resulted in a marked shift in whether PCIs done in 2003-2004 were considered indicated. Guideline-based performance measures should be carefully evaluated before implementation to avoid incorrect assessments of quality of care.

108 Is the UK underestimating the importance of left ventricular function assessment in contemporary PCI?

Introduction The impact of left ventricular ejection fraction (LVEF) on outcome in contemporary percutaneous coronary intervention (PCI) is unclear. The British Cardiovascular Intervention Society (BCIS) audit data suggest that in the UK, only 46% of all patients undergoing PCI have LV function assessment prior to their procedure. The North West Quality Improvement Programme (NWQIP) risk-prediction model does not include LVEF as a potential predictor of adverse outcome. LVEF is also not included in current American and European PCI guidelines. We set out to clarify its impact on early and long-term survival following PCI in a large, contemporary single centre cohort. Methods Consecutive patients undergoing PCI between 2005 and 2009 at St. Thomas’ Hospital, London, UK were included. LVEF was determined by echocardiography or LV angiography and categorised as Good (EF≥50%), Moderate (31–49%) or Poor (≤30%) at the time of PCI. The primary endpoint was 30-day all-cause mortality and the secondary endpoint was long-term all-cause mortality. Predictors of outcome were assessed by univariate and multivariate analyses. Data are mean±SD. Results Two thousand three hundred and sixty patients who had been categorised according to LVEF at the time of PCI were included (aged 65±11.1 years). 43% presented as acute coronary syndromes. Drug-Eluting stents were used in 53% of cases. 30-day mortality rates were inversely correlated with LVEF, being 0.5%, 2.1% and 8.8% for patients with good, moderate and poor LVEF respectively (p Conclusion LVEF is a strong predictor of early and long-term outcome following PCI. The importance of LVEF, as a simple method of stratifying risk should be emphasised more strongly in risk-stratification models and included in UK and international PCI guidelines. LV function should be assessed routinely before all PCI procedures.

Development of clinical practice guidelines for the nursing care of people undergoing percutaneous coronary interventions: An Australian & New Zealand collaboration

This paper describes the development of nursing practice guidelines for percutaneous coronary intervention (PCI). Clinical practice guidelines (CPGs) supporting PCI nursing care are limited. The National Health and Medical Research Council's (NH&MRC) health and medical practice development guidelines were used for the guideline development process. A panel of experts (clinicians and consumers) attended a consensus conference to review existing evidence. Subsequently, nurses' opinions were identified via an online survey. This was followed by a modified Delphi method was used to refine a draft set of guidelines over two rounds. The consensus conference was attended by 41 participants (39 cardiovascular nurses and 2 consumer representatives). Eight additional members joined the panel for the modified Delphi rounds with 27 participants completing the online survey. The final guideline document consisted of 75 recommendations. Endorsement was then sought from key peak cardiovascular bodies in Australia and New Zealand. Inconclusive evidence precludes definitive recommendations. Therefore, consultation and consensus are important in developing guidelines to achieve standardised nursing care and monitoring of outcomes. Nurses play a crucial role in PCI care, yet currently there are limited guidelines to inform practice. This paper describes the method developing clinical practice guideline and deriving consensus.

Use of platelet glycoprotein IIb/IIIa inhibitors in diabetics undergoing PCI for non-ST-segment elevation acute coronary syndromes: impact of clinical status and procedural characteristics

BackgroundThe most recent ESC guidelines for percutaneous coronary intervention (PCI) recommend the use of glycoprotein IIb/IIIa inhibitors (GPI) in high risk patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS), particularly in diabetics. Little is known about the adherence to these guidelines within Europe.Methods and resultsBetween May 2005 and April 2008 a total of 47,407 consecutive patients undergoing PCI were prospectively enrolled into the PCI-Registry of the Euro Heart Survey Programme. In the present analysis we examined the use of GPI in 2,922 diabetics who underwent PCI for NSTE-ACS. In this high risk population only 22.2% received a GPI; 8.9% upstream and 13.4% during PCI. The strategy of the individual institution had a major impact on the usage of GPI. In the multiple regression analysis clinical instability and complex lesion characteristics were strong independent determinants for the use of GPI, whereas renal insufficiency was negatively associated with its use. After adjustment for confounding variables no significant differences in hospital mortality could be observed between the cohorts, but a significantly higher rate of non-fatal postprocedural myocardial infarction was observed among patients receiving GPI upstream.ConclusionsDespite the recommendation for its use in the current ESC guidelines, only a minority of the diabetics in Europe undergoing PCI for NSTE-ACS received a GPI. The use of GPI was mainly triggered by high-risk interventional scenarios.

2009 Focused Updates to Guidelines in ST-Elevation Myocardial Infarction and Percutaneous Coronary Intervention: Application to Interventional Cardiology

Practice guidelines reflect a consensus of expert opinion for patient care after a thorough review of clinical trials relevant to a given patient population. However, in keeping pace with the influx of new data, these recommendations need to be revised periodically to remain current. The American College of Cardiology (ACC) and the American Heart Association (AHA) published the Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction in 2004 and the Guidelines for Percutaneous Coronary Intervention in 2005 with their respective Focused Updates in 2007. Now, 2 years later, further revision of these guidelines has been published as Focused Updates of 2009.

Clinical Summaries

Clinical Summaries

Adherence of Catheterization Laboratory Cardiologists to American College of Cardiology/American Heart Association Guidelines for Percutaneous Coronary Interventions and Coronary Artery Bypass Graft Surgery

The American College of Cardiology and the American Heart Association have issued guidelines for the use of coronary artery bypass graft surgery (CABG) and percutaneous coronary interventions (PCI) for many years, but little is known about the impact of these evidence-based guidelines on referral decisions. A cardiac catheterization laboratory database used by 19 hospitals in New York State was used to identify treatment (CABG surgery, PCI, medical treatment, or nothing) recommended by the catheterization laboratory cardiologist for patients undergoing catheterization with asymptomatic/mild angina, stable angina, and unstable angina/non-ST-elevation myocardial infarction between January 1, 2005, and August 31, 2007. The recommended treatment was compared with indications for these patients based on American College of Cardiology/American Heart Association guidelines. Of the 16 142 patients undergoing catheterization who were found to have coronary artery disease, the catheterization laboratory cardiologist was the final source of recommendation for 10 333 patients (64%). Of these 10 333 patients, 13% had indications for CABG surgery, 59% for PCI, and 17% for both CABG surgery and PCI. Of the patients who had indications for CABG surgery, 53% were recommended for CABG and 34% for PCI. Of the patients with indications for PCI, 94% were recommended for PCI. For the patients who had indications for both CABG surgery and PCI, 93% were recommended for PCI and 5% for CABG surgery. Catheterization laboratory cardiologists in hospitals with PCI capability were more likely to recommend patients for PCI than hospitals in which only catheterization was performed. Patients with coronary artery disease receive more recommendations for PCI and fewer recommendations for CABG surgery than indicated in the American College of Cardiology/American Heart Association guidelines.

Aspectos contemporâneos da intervenção coronária percutânea no tratamento eletivo de estenoses localizadas no tronco não-protegido da artéria coronária esquerda

A intervenção coronária percutânea (ICP) em tronco da artéria coronária esquerda (TCE) não-protegido era considerada até bem pouco tempo uma terapia proscrita em indivíduos elegíveis à revascularização cirúrgica convencional (RM), padrão de referência no tratamento dessa enfermidade. Esse conceito foi embasado nas elevadas taxas de eventos cardíacos adversos maiores em pacientes tratados com ICP com balão e, posteriormente, em pacientes tratados com stents não-farmacológicos. Mais recentemente, a introdução dos stents farmacológicos em nossa prática clínica diária promoveu redução substancial das taxas de reestenose e eventos cardíacos adversos maiores em pacientes tratados percutaneamente. Os bons resultados obtidos motivaram revisões das principais diretrizes, que passaram a considerar esse tratamento uma opção viável, variando seu nível de indicação conforme a complexidade clínica, bem como a anatomia coronária a ser abordada. Contudo, apesar desse importante avanço, alguns pontos devem ser destacados: a abordagem da bifurcação distal está associada a pior evolução em comparação ao tratamento do óstio ou corpo, sendo a técnica do T provisional a mais indicada nessa situação. Não foram estabelecidas, até o momento, diferenças substanciais nos desfechos entre os distintos stents farmacológicos, e seu implante, auxiliado por métodos de imagem intravasculares, deve ser incentivado. Finalmente, a avaliação e a seleção dos pacientes para o procedimento devem ser orientadas por meio de escores que avaliem características clínicas e angiográficas.

Antiplatelet effects of clopidogrel and bleeding in patients undergoing coronary stent placement.

In patients undergoing percutaneous coronary intervention (PCI), a link between bleeding and excess mortality has been demonstrated. A potential association of platelet response to clopidogrel and bleeding has not been well established yet. The aim of the present study was to assess the impact of clopidogrel responsiveness on the risk of bleeding in clopidogrel-treated patients undergoing PCI. Patients (n=2533) undergoing PCI after pretreatment with 600 mg of clopidogrel were enrolled in this study. Blood was obtained directly before PCI. Adenosine-diphosphate (ADP)-induced platelet aggregation was assessed on a Multiplate analyzer. The primary endpoint was the incidence of in-hospital Thrombolysis in Myocardial Infarction (TIMI) major bleeding and the secondary endpoint was in-hospital TIMI minor bleeding. Receiver-operator curve (ROC) analysis was used to derive the optimal platelet aggregation value defining enhanced clopidogrel responders for the association of measurements with major bleeding. Thirty-four (1.3%) major bleeding events and 137 (5.4%) minor bleeding events were observed. The risk of a major bleeding was significantly higher in patients (n=975) with an enhanced response to clopidogrel as compared with the remaining patients (n=1558) (2.2 vs. 0.8%, unadjusted odds ratio (OR) 2.6, 95% confidence interval (CI) 1.3-5.2, P=0.005; adjusted OR 3.5, 95% CI 1.6-7.3, P=0.001). No significant differences between both groups were observed for the occurrence of minor bleeding events (P=0.68). Enhanced clopidogrel responsiveness is associated with a higher risk of major bleeding. Whether guidance of antiplatelet treatment based on platelet function testing proves useful for avoiding bleeding events warrants further investigation.

Tirofiban administration and percutaneous coronary intervention with stenting of saphenous vein graft thrombosis

Distal embolization during percutaneous coronary intervention (PCI) of saphenous vein graft (SVG) lesions is associated with a high risk of myonecrosis and myocardial infarction. PCI guidelines advocate the use of distal embolic protection devices, when technically feasible, in patients undergoing PCI for SVG disease. To date, alternative management strategies are not fully investigated. We report a case of an 84-year-old male patient with acute coronary syndrome who underwent PCI for a quite occlusive stenosis of an SVG on the first diagonal branch of the left anterior descending artery complicated by wide endoluminal thrombosis with poor antegrade coronary blood flow and absent opacity of the distal first diagonal vessel. A strategy of delayed PCI after upstream, 48 h long tirofiban administration in order to obtain a thrombus burden reduction was decided. After tirofiban administration, a high-level thrombus resolution was obtained, with a significant improvement in coronary flow, and a successful PCI with stenting was performed. There was neither clinical nor instrumental periprocedural sign of ischemia, and the patient remained asymptomatic throughout his hospital stay. Preprocedural tirofiban administration followed by PCI with stenting of an SVG thrombotic lesion without a distal protection device might be a well-tolerated and feasible option for patients with degenerated SVG disease. Further studies are needed to further expand our findings.

Percutaneous Revascularization Is the Preferred Strategy for Patients With Significant Left Main Coronary Stenosis

In the early 1970s, coronary artery bypass graft (CABG) was found to improve late survival in comparison to medical therapy in patients with significant left main stenosis.1–3 Once CABG became the standard of care for left main disease, a distinction between “protected”—by at least 1 patent bypass graft to the left coronary artery—and “unprotected left main (UPLM)”— no patent bypass graft to the left coronary artery—was made. In the 1980s, early attempts at balloon angioplasty of UPLM stenoses were associated with poor early outcomes because of coronary dissection, abrupt closure, and restenosis. Mortality rates as high as 30% at 1 year were reported.4–6 In the 1990s, bare metal stents were introduced and soon used to treat UPLM disease. Several small registries found a low rate of procedural complications, but repeat revascularization rates of 20% to 30% because of restenosis were considered unacceptable.7–12 Early bare metal stent registries for UPLM also found high mortality rates, particularly in high-risk patients, such as patients with acute coronary syndromes and poor left ventricular function. Importantly, high-risk subgroups often presented with late sudden death after stenting.11,13 In the early 2000s, the introduction of drug-eluting stents (DES), with the promise of vastly reduced rates of restenosis,14–17 raised the possibility of improved late outcomes in this challenging patient group. Response by Smith p 1033 Clinical outcomes after treatment of UPLM disease with either the sirolimus-eluting stent or the paclitaxel-eluting stent from >20 small registries have been published. Results reported in these registries vary widely.18–40 As depicted in Table 1, cardiac mortality between 6 and 12 months after the procedure ranges from 0% to 11%. Target lesion revascularization (TLR) or target vessel revascularization (TVR) rates range from 2% to 38%. This wide variation in clinical outcome appears largely because of variation …

Platelet function analysis: At the edge of meaning

Platelet function analysis: At the edge of meaning

Abstract 4590: Safety and Efficacy of Prolonged Use of Unfractionated Heparin After Percuatneous Coronary Intervention: A Meta-Analysis

The current guidelines for percutaneous coronary intervention (PCI) do not address the prolonged post-procedural use of unfractionated heparin (UFH) to prevent acute occlusion. However, recently published small studies have yielded mixed results, leaving the question unanswered. Hence a meta-analysis was performed to evaluate safety and efficacy of prolonged use of UFH after PCI. A systematic review of literature revealed 7 studies (Juergens et al, Rabah et al, Garachemani et al, Pizzulli et al, Freidman et al, Tanajura et al and Ellis et al) involving 2412 patients. End points analyzed were ischemic complications (acute closure, myocardial infarction and repeat revascularization) and major vascular complications (hematoma, arterio-venous fistula, pseudo-aneurysm and retroperitoneal bleed). Since the studies were homogenous for outcomes, combined relative risks (RR) across all the studies and the 95% confidence intervals were computed using the Mantel-Haenszel fixed-effect model. A two-sided alpha error &lt; 0.05 was considered to be statistically significant. There were no significant differences in patient demographics between both groups. Compared with placebo the risk of major vascular complication was significantly higher in patients getting post-procedural UFH for prolonged hours (RR: 2.24, CI: 1.68 – 3.48; p=0.001). However, the risk of ischemic complications was similar in both groups (RR: 0.95, CI: 0.46 – 1.96; p=0.89). The meta-analysis suggests that prolonged use of UFH after PCI may result in increased major vascular complications, even though the incidence of ischemic complications may not decrease.

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.