Invasive assessment of culprit and non-culprit coronary lesions in patients with acute coronary syndromes

For decades, coronary angiography has been the gold standard for identifying and evaluating culprit and non-culprit coronary lesions in acute coronary syndromes (ACS). However, angiography provides limited information on plaque composition and cannot assess the functional significance of lesions. To address these limitations, several invasive methods have been introduced and are now used in clinical practice, including intravascular imaging (IVI) and fractional flow reserve (FFR). Studies have compared FFR-guided complete revascularization with culprit-only revascularization, as well as FFR-guided versus angiography-guided revascularization in both ACS and stable angina. However, clinical trials in ACS have produced contradictory results: some studies indicate that FFR is feasible, safe, and associated with reduced major adverse cardiac events (MACE), while others are less conclusive. IVI has been evaluated in fewer ACS-specific studies, but initial findings are promising. Moreover, a novel strategy has emerged: preemptive stenting of high-risk, hemodynamically non-significant plaques identified by IVI to prevent future MACE. Nevertheless, the limited and sometimes contradictory data highlight the need for further research to determine the optimal diagnostic and treatment strategies for coronary lesions in patients with ACS.