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FLOWER-MI and the root of the problem with non-culprit revascularisation
Matthew E Li Kam Wa1,2, Kalpa De Silva3,2, Carlos Collet4
1Cardiovascular Division, Guy's and St Thomas' NHS Foundation Trust, London, UK mlikamwa@nhs.net.
Insights
The FLOWER-MI trial investigated using a specific index to guide percutaneous coronary intervention (PCI) for non-culprit lesions in ST-elevation myocardial infarction. Results suggest this index does not improve outcomes compared to standard angiography-guided PCI.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Percutaneous coronary intervention (PCI) benefits for non-culprit lesions in ST-elevation myocardial infarction (STEMI) are established.
- The role of physiological assessment for non-culprit lesions in STEMI remains debated.
- Existing indices for stable coronary disease may not translate to STEMI management.
Purpose of the Study:
- To evaluate the incremental benefit of a specific index for guiding PCI in non-culprit lesions during STEMI.
- To determine if lesion significance predicts future myocardial infarction risk.
- To explore advanced methods for guiding non-culprit revascularization decisions.
Main Methods:
- The study examined the design and results of the FLOW Evaluation to Guide Revascularization in Multi-vessel ST-elevation Myocardial Infarction (FLOWER-MI) trial.
- Analysis focused on the utility of a lesion significance index versus angiography-guided PCI.
- Investigated the relationship between baseline lesion physiology and future cardiac events.
Main Results:
- The FLOWER-MI trial did not demonstrate an incremental benefit of the tested index over angiography-guided PCI for non-culprit lesions in STEMI.
- No significant correlation was found between baseline physiological significance and future myocardial infarction risk.
- Current angiography-guided strategies remain the standard for non-culprit lesion management in STEMI.
Conclusions:
- Physiological assessment using the studied index does not enhance outcomes for non-culprit PCI in STEMI.
- Angiographic guidance is sufficient for managing non-culprit lesions in this setting.
- Further research into advanced methods for guiding revascularization is warranted.
Abstract:
How do we reduce cardiac death and myocardial infarction by percutaneous coronary intervention (PCI) in coronary heart disease? Although the interventional community continues to grapple with this question in stable angina, the benefits of PCI for non-culprit lesions found at ST-elevation myocardial infarction are established. Is it then wishful thinking that an index developed in stable coronary disease, for identifying lesions capable of causing ischaemia will show an incremental benefit over angiographically guided non-culprit PCI? This is the question posed by the recently published FLOW Evaluation to Guide Revascularization in Multi-vessel ST-elevation Myocardial Infarction (FLOWER-MI) trial. We examine the trial design and results; ask if there is any relationship between the baseline physiological significance of a non-culprit lesion and vulnerability to future myocardial infarction; and consider if more sophisticated methods can help guide or defer non-culprit revascularisation.
