Management of multivessel disease in patients with ST-segment elevation myocardial infarction: questioning routine immediate complete revascularization in all patients.

Primary percutaneous coronary intervention (PCI) of the culprit lesion is the preferred treatment in ST-segment elevation myocardial infarction (STEMI). However, in nearly half of all patients, multivessel coronary artery disease is present, raising fundamental questions: should non-culprit lesions be treated at all, and if so, should revascularization be performed immediately or in a staged fashion? Furthermore, should lesion selection be guided by angiography or by functional and imaging-based assessment? Over the past decade, landmark trials shifted clinical practice and formed the basis for current guideline recommendations of the European Society of Cardiology, advocating routine complete revascularization within 45 days in all hemodynamically stable patients. Yet, recently published evidence has challenged this paradigm. New randomized trials exploring the timing and guidance of non-culprit lesion PCI have yielded heterogeneous and, at times, conflicting results. While some suggest that immediate complete revascularization is safe, others raise concerns in patients with impaired cardiac function. Another recently published trial introduces a novel concept by directly comparing immediate physiology-guided PCI with a staged, noninvasive ischemia-guided strategy, demonstrating similar long-term outcomes with substantially fewer interventions. Together, these findings are reshaping the current view of the management of multivessel disease in STEMI. The metaphoric 'therapeutic pendulum' - after swinging firmly towards immediate complete revascularization - is beginning to swing back towards a more individualized, physiology- and imaging-based approach. The central aim of this review is to evaluate whether this individualized staged physiology- and imaging-based approach is a valid alternative to immediate complete revascularization. Clarifying which patients truly benefit from immediate complete revascularization remains a pivotal challenge for future clinical research and guideline development.