The following are key points to remember from this state-of-the-art review on the evaluation and management of nonculprit lesions (NCLs) in ST-segment elevation myocardial infarction (STEMI) patients:

1. NCLs are frequently observed in patients presenting with STEMI.
2. Results from recent randomized clinical trials suggest that complete revascularization after STEMI improves outcomes.
3. This state-of-the-art paper reviews these trials and recommends how best to determine which NCLs require revascularization and the timing of procedure.
4. While available data suggest benefit from complete revascularization in patients with STEMI, data are less conclusive concerning the optimal methods for evaluation and timing of NCL revascularization.
5. Acute and subacute physiological changes may affect the evaluation of NCLs during the index procedure and the index hospitalization.
6. Because of the transient physiological changes in STEMI, angiography and instantaneous wave-free ratio (iFR) may overestimate and fractional flow reserve may underestimate NCL severity.
7. As there are no data comparing different approaches to determining the functional significance of NCLs after STEMI, clinicians should use the methods they are most familiar with and take the possible effects of STEMI and the timing of evaluation after STEMI into account while interpreting results.
8. The optimal timing of evaluation and revascularization of NCLs remains to be established, and there is a need for future prospective trials to address these questions.
9. In the absence of larger trials comparing immediate versus staged complete revascularization, it is generally recommended that NCL revascularization be performed in a staged setting, but functional assessment at the index procedure can be considered to justify or prevent a second procedure.
10. However, immediate complete revascularization may be reasonable during the index procedure when NCL functional significance is unequivocal and percutaneous coronary intervention is expected to be well tolerated.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Prevention, Stable Ischemic Heart Disease, Vascular Medicine, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Chronic Angina

Keywords: Angiography, Anterior Wall Myocardial Infarction, Fractional Flow Reserve, Myocardial, Myocardial Infarction, Percutaneous Coronary Intervention, Secondary Prevention, ST Elevation Myocardial Infarction

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