Is there a role for ischemia detection after an acute myocardial infarction?

Coronary angiography and eventual revascularization have become the most common approaches for patients with acute coronary syndromes. Ischemia detection in this scenario is usually regarded as unnecessary for most of the patients. In fact, current guidelines recommend complete revascularization for patients with multivessel disease in the context of ST-elevation myocardial infarction, although it is in contrast with previous recommendations. However, some recent data suggested that ischemia could have a role for the decision of revascularization in these patients. The CROSS-AMI study randomized patients with ST-elevation myocardial infarction treated with primary angioplasty and who also had multivessel disease to a complete anatomic revascularization of the non-infarct related artery lesions vs subsequent revascularization of the non-infarct related artery lesions only if ischemia was demonstrated by stress echocardiography. The main findings were that only 30% of the patients in the ischemia arm needed a second revascularization and that the outcome was similar in both arms. Regarding non-ST-elevation acute coronary syndrome, coronary angiography is in general warranted for most of the patients. However, recent long-term published studies on patients randomized to an invasive or less aggressive approach based on ischemia detection have found no differences in outcome. The ultimate study in non-ST-elevation acute coronary syndrome comparing ischemia detection with an invasive approach is pending. Therefore, ischemia detection might have a role for stratifying these subjects. This is particularly true in the current era of imaging of high quality and sensitivity, last generation stents, radial access and modern antithrombotic therapy.