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Should fractional flow reserve follow angiographic visual inspection to guide preventive percutaneous coronary
David S Wald1, Steven Hadyanto1, Jonathan P Bestwick1
1Wolfson Institute of Preventive Medicine, Queen Mary University of London Charterhouse Square, London EC1M6BQ, UK.
Insights
Preventive percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) patients significantly reduces cardiac death and myocardial infarction (MI) when guided by angiographic visual inspection alone. Adding fractional flow reserve (FFR) to this assessment diminishes these benefits.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- ST-elevation myocardial infarction (STEMI) management often involves percutaneous coronary intervention (PCI) to address the infarct-related artery.
- The role of preventive PCI in non-infarct arteries in STEMI patients remains a subject of investigation.
- Decision-making for preventive PCI is typically based on angiographic visual inspection (AVI) or a combination of AVI and fractional flow reserve (FFR).
Purpose of the Study:
- To quantify the impact of preventive PCI in non-infarct arteries on cardiac death and non-fatal myocardial infarction (MI) in STEMI patients.
- To compare the outcomes of preventive PCI guided by AVI alone versus AVI plus FFR.
Main Methods:
- A systematic literature search identified randomized trials comparing preventive PCI with no preventive PCI in STEMI patients without shock.
- Trials were categorized based on the method used to select patients for preventive PCI: AVI alone or AVI plus FFR.
- Random effects meta-analyses were performed to compare outcomes between the two categories.
Main Results:
- Eleven eligible trials were included in the meta-analyses.
- Preventive PCI guided by AVI alone showed a significant reduction in the combined outcome of cardiac death and MI (RR 0.39) and in MI alone (RR 0.41).
- When FFR was added to AVI for patient selection, the benefit of preventive PCI was attenuated, with no significant reduction in cardiac death and MI (RR 0.85) or MI alone (RR 0.98).
Conclusions:
- In STEMI patients, preventive PCI in non-infarct arteries guided by AVI alone significantly reduces cardiac death and MI.
- Utilizing FFR in addition to AVI for selecting patients for preventive PCI in this context appears to diminish the observed benefits.
- Angiographic visual inspection alone is recommended for guiding preventive PCI decisions in STEMI patients to maximize therapeutic advantages.
Aims:
We aimed to quantify the effect of preventive percutaneous coronary intervention (PCI to non-infarct arteries) on cardiac death and non-fatal myocardial infarction (MI) in patients with ST-elevation myocardial infarction (STEMI) according to whether the decision to carry out preventive PCI was based on angiographic visual inspection (AVI alone) or AVI plus fractional flow reserve (FFR) if AVI showed significant stenosis (AVI plus FFR).
Methods And Results:
Randomized trials comparing preventive PCI with no preventive PCI in STEMI without shock were identified by a systematic literature search and categorized according to whether they used AVI alone or AVI plus FFR to select patients for preventive PCI. Random effects meta-analyses and tests of heterogeneity were used to compare the two categories in respect of cardiac death and MI as a combined outcome and individually. Eleven eligible trials were identified. For cardiac death and MI, the relative risk estimates for AVI alone vs. AVI plus FFR were 0.39 (0.25-0.61) and 0.85 (0.57-1.28), respectively (P = 0.01 for difference), for cardiac death, alone the estimates were 0.36 (0.19-0.71) and 0.79 (0.36-1.77), respectively (P = 0.15 for difference), and for MI alone, 0.41 (0.23-0.73) and 0.98 (0.62-1.56), respectively (P = 0.04 for difference).
Conclusion:
In preventive PCI among STEMI patients, AVI alone achieves a ∼60% reduction in cardiac death and MI but selecting patients using FFR in AVI positive patients loses much of the benefit. Angiographic visual inspection is best used without FFR in this group of patients.
