I have read with great interest the article entitled “Multivessel Versus Culprit-only Percutaneous Coronary Intervention in ST-segment Elevation Acute Myocardial Infarction: Analysis of an 8-year Registry” by Galvão Braga et al.1 published in your journal. The investigators reported that in patients with ST-segment elevation acute myocardial infarction and multivessel coronary artery disease, a multivessel percutaneous coronary intervention strategy was associated with lower rates of mortality, unplanned repeat revascularization, and major acute cardiovascular events.1

The angiographic-based SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery) score (SS) has consistently been shown to be an independent predictor of major acute cardiovascular events.2 Several reasons might be related to the increased risk of major acute cardiovascular events in patients with high SS, including a higher number of obstructive plaques, a larger necrotic core, and more complex lesions. Angiographic diameter stenosis of the nonculprit plaques in the high SS group was significantly higher than that in the intermediate and low SS groups. The high SS group had a significantly lower minimum fibrous cap thickness in the culprit lesion than the intermediate and low SS groups. Additionally, the minimum fibrous cap thickness in the nonculprit lesion was significantly lower in the high SS group than in the intermediate and low SS groups. The frequencies of lipid-rich plaque, thin cap fibroatheroma, and plaque rupture in the culprit lesion were significantly higher in the high SS group than in the intermediate and low SS groups. These findings imply that patients with high SS may have increased plaque vulnerability in culprit as well as nonculprit lesions. In addition, the increased vulnerability of nonculprit plaques in patients with high SS might thus provoke fatal or nonfatal coronary events even after successful revascularization for culprit lesions. SS after percutaneous coronary intervention was at least as strong a predictor of subsequent ischemic events as SS calculated before percutaneous coronary intervention.3,4 Iqbal et al.5 reported that multivessel intervention may be considered in patients with nonculprit left anterior descending artery disease.

In light of this knowledge, a new scoring system including parameters, such as SS, nonculprit left anterior descending artery disease, renal disease, and severe left ventricular dysfunction, may shed light to determine of revascularization strategy in patients with ST-segment elevation acute myocardial infarction and multivessel disease.