Infarct related culprit Versus Non- culprit vessel revascularization

A 38 year old male smoker and hypertensive presented with severe retrosternal chest pain of 3 hours duration. On examination he was hypertensive with BP = 80/50 sinus bradycardia with HR 40bpm, right sided S3 and chest clear. He recently underwent primary PCI to LAD a month ago, coronary angiogram at that time revealed LAD 90% stenosis, LCX mid 50% stenosis, RCA proximal 60-70% stenosis and Right PDA has 80% osteal stenosis. 

ECG on current presentation showed sinus bradycardia and ST depressions more than 2mm in inferior leads. Please give answer of following questions based on guidelines

a)      Is TPM indicated, if yes then give justification

b)      Name the culprit vessel

c)      Do you think revascularization of non-culprit vessel at time of primary PCI would have prevented current cardiac event

d)      Name the trials which have studied such scenarios

Answers:

a. Yes, Symptomatic bradycardia
b. RCA/PDA
c. Yes
d. DANAMI, PRAGUE, CULPRIT and PRAMI Trail (Infarct related culprit Vs. non- culprit vessel revascularization)

Reference:

1.      Chapter 22, page 390 – Bradyarrythmias - Manual of Cardiovascular Medicine Fourth Edition - Brian P. Griffin MD FACC

2.      Engstrom T, Kelbaek H, Helqvist S, et al. Complete revascularization versus treatment of the culprit lesion only in patients with ST segment elevation myocardial infarction and multi vessel disease (DANAMI 3- PRIMULTI) an open – label randomized controlled trial. Lancet 2015;386:665-71.10.1016/S0140-6736(15)60648-1 [Pubmed]