Perspective:

No single approach may be applicable to the myriad presentations of ST-segment elevation myocardial infarction (STEMI). A reasonable first step would be to perform right and left coronary artery angiography to assess the entire coronary anatomy before a lesion is targeted for percutaneous coronary intervention (PCI). For patients with severe multivessel coronary artery disease, follow-up angiography or noninvasive testing is reasonable. Fractional flow reserve should be used whenever possible to support a decision for staged PCI. It should be noted that current practice guidelines do not support the practice of multivessel PCI during nonshock STEMI. It is possible that multivessel PCI may be necessary in some STEMI patients who have multiple complex lesions and do not improve after culprit PCI. However, such a decision should be taken in conjunction with the cardiologist or other physicians taking care of the patient, including the cardiac surgeon, whenever feasible.