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Zahrai et al. Vessel Plus 2023;7:32 https://dx.doi.org/10.20517/2574-1209.2023.100 Page 3 of 13

CURRENT STATE OF AFFAIRS AND GUIDELINE REVIEW
The most recent American College of Cardiology/American Heart Association/Society of Cardiovascular
Angiographic Interventions guidelines on the management of acute ST-Elevation Myocardial Infarction
(STEMI) patients assigns a class 1 recommendation to primary PCI in patients with ischemic symptoms for
[26]
< 12 h, to improve survival . This recommendation is based on high-quality evidence, including the
[27]
Primary Angioplasty in Myocardial Infarction (PAMI) and the Global Use of Strategies to Open
[28]
Occluded Coronary Artery in ACS (GUSTO IIb) trials, both comparing primary percutaneous
transluminal coronary angioplasty and thrombolysis. A sub-analysis of the GUSTO IIb study subsequently
[29]
demonstrated that time to revascularization was intrinsically linked to mortality . This led to the rise of the
concept of “door-to-balloon” time, which should ideally be below 90 min and should not exceed 120 min
from symptom onset .
[26]

In patients with STEMI and multivessel CAD, revascularization of residual coronary artery stenoses can be
achieved via surgical or percutaneous therapies, depending on patient factors (such as social situation, age,
diabetes, and other comorbidities) and severity and complexity of the non-culprit coronary disease.
Revascularization strategies include: multivessel PCI at the time of primary PCI, primary PCI followed by
staged PCI, PCI on the culprit artery only, followed by an ischemia-guided PCI of the remaining vessels,
and primary PCI followed by CABG. The option of primary PCI followed by staged PCI is endorsed by
strong evidence, thereby justifying the class 1 recommendation for this strategy in the latest American
guidelines on coronary revascularization . In contrast, a class 2a recommendation was attributed to
[26]
surgical revascularization in patients with residual complex multivessel non-culprit artery disease after
successful primary PCI [Table 1]. This recommendation is largely based on the consensus of expert opinion
rather than clinical data. Interestingly, in the 2021 American and 2023 European guidelines [Table 2],
[30]
[26]
there is no mention of optimal timing for subsequent surgical revascularization in patients who undergo
primary PCI for STEMI.

CLINICAL IMPACT OF TIMING OF SURGICAL REVASCULARIZATION AFTER PRIMARY
PCI
The principal goal of optimizing the timing of CABG after primary PCI is to minimize surgical mortality
and major cardiac and cerebrovascular events (MACCE). When emergent surgery is performed within 48 h
of acute coronary syndrome (ACS), the mortality rate can reach 1,520%, compared to 4%-5% when surgery
occurs after 48 h [31-33] . Table 3 provides a summary of the major studies that have addressed the timing of
surgery in the context of ACS.

A recent systematic review and meta-analysis by Lang et al. further support the role of delayed surgery .
[34]
The authors analyzed 19 studies and 113,984 AMI participants who underwent staged CABG. Included
studies assessed mortality and/or MACCE as a function of the timing of surgery. Early surgery was defined
as CABG within 24-48 h of AMI, while late surgery occurred anytime thereafter. In-hospital mortality was
significantly higher in patients who underwent CABG < 24 h, compared to those who had surgery > 24 h
(OR 2.65; 95%CI: 1.96 to 3.58; P < 0.00001). Similarly, patients who underwent CABG < 48 h had a
significantly higher in-hospital mortality than those who underwent surgery > 48 h (OR 1.91; 95%CI: 1.11 to
3.29; P = 0.02). There was no difference between early and late CABG with regards to perioperative MI (OR
1.38; 95%CI: 0.41 to 4.72; P = 0.60) and cerebrovascular accidents (OR 1.31; 95%CI: 0.72 to 2.39; P = 0.38).