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Published on: March 12, 2018
FFR-Guided Complete or Culprit-Only PCI in Patients with Myocardial Infarction
Felix Böhm1, Brynjölfur Mogensen1, Thomas Engstrøm1
1From the Department of Cardiology, Karolinska Institute and Danderyd Hospital, Danderyd (F.B., B.M., R.L.), the Department of Cardiology, Karolinska Institute and Karolinska University Hospital, Stockholm (A.R.), the Department of Cardiology, Linköping University Hospital, Linköping (S.Z.), the Department of Cardiology, Mälarsjukhuset, Eskilstuna (M.H.), the Department of Cardiology, Central Hospital, Karlstad (T.K.), the Department of Cardiology, Ryhov Hospital, Jönköping (J. Lauermann), the Department of Cardiology, Umeå University Hospital, Umeå (J.A.), the Department of Cardiology, Sahlgrenska University Hospital, and the Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg (O.A.), and the Department of Medical Sciences, Cardiology (H.R., C.H., O.Ö., S.J.), and Uppsala Clinical Research Center (C.H., S.J.), Uppsala University, Uppsala - all in Sweden; the Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen (T.E., J. Lønborg); the University Clinical Center of Serbia and the Faculty of Medicine, University of Belgrade, Belgrade (G.S.), and the Faculty of Medicine, University of Novi Sad, Institute of Cardiovascular Diseases Vojvodina, Sremska Kamenica (I.S.) - all in Serbia; the Heart Hospital, Tampere University Hospital, and the Faculty of Medicine and Health Technology, Tampere University, Tampere (O.A.K.), and the Heart and Lung Center, Helsinki University Central Hospital, Helsinki (M.L.) - all in Finland; the Latvian Center of Cardiology, Pauls Stradins Clinical University Hospital, University of Latvia, Riga (A..); the Cardiology Department, Waikato Hospital, Hamilton, New Zealand (M.M.); and the Medical School, University of Western Australia, and the Department of Cardiology, Royal Perth Hospital - both in Perth, WA (C.S.).
Insights
Fractional flow reserve (FFR)-guided complete revascularization did not significantly reduce adverse events in ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease compared to culprit-lesion-only PCI. This finding suggests no added benefit for comprehensive treatment in this high-risk group.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- The clinical benefit of complete revascularization guided by fractional flow reserve (FFR) in ST-segment elevation myocardial infarction (STEMI) patients with multivessel coronary artery disease is not well-established.
- Multivessel coronary artery disease in STEMI patients presents a complex treatment scenario requiring careful consideration of revascularization strategies.
Purpose of the Study:
- To evaluate the efficacy of FFR-guided complete revascularization versus culprit-lesion-only percutaneous coronary intervention (PCI) in patients with STEMI and multivessel coronary artery disease.
- To determine if a strategy of complete revascularization improves clinical outcomes in this specific patient population.
Main Methods:
- A multinational, registry-based, randomized trial involving 1542 patients with STEMI or very-high-risk non-STEMI (NSTEMI) and multivessel disease.
- Patients undergoing primary PCI of the culprit lesion were randomized to either FFR-guided complete revascularization of nonculprit lesions or culprit-lesion-only PCI.
- The primary outcome was a composite of death from any cause, myocardial infarction, or unplanned revascularization, with a median follow-up of 4.8 years.
Main Results:
- No significant difference was observed in the primary outcome between the FFR-guided complete revascularization group (19.0%) and the culprit-lesion-only PCI group (20.4%) (hazard ratio, 0.93; 95% CI, 0.74 to 1.17; P=0.53).
- Secondary outcomes, including death or myocardial infarction and unplanned revascularization, also showed no significant between-group differences.
- Safety outcomes were comparable between the two treatment strategies.
Conclusions:
- FFR-guided complete revascularization did not demonstrate a significant reduction in the composite outcome of death, myocardial infarction, or unplanned revascularization compared to culprit-lesion-only PCI in patients with STEMI and multivessel coronary artery disease.
- The findings suggest that for this patient cohort, the addition of FFR-guided complete revascularization does not offer a significant clinical advantage over standard culprit-lesion-only PCI at nearly 5-year follow-up.
Background:
The benefit of fractional flow reserve (FFR)-guided complete revascularization in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease remains unclear.
Methods:
In this multinational, registry-based, randomized trial, we assigned patients with STEMI or very-high-risk non-STEMI (NSTEMI) and multivessel disease who were undergoing primary percutaneous coronary intervention (PCI) of the culprit lesion to receive either FFR-guided complete revascularization of nonculprit lesions or no further revascularization. The primary outcome was a composite of death from any cause, myocardial infarction, or unplanned revascularization. The two key secondary outcomes were a composite of death from any cause or myocardial infarction and unplanned revascularization.
Results:
A total of 1542 patients underwent randomization, with 764 assigned to receive FFR-guided complete revascularization and 778 assigned to receive culprit-lesion-only PCI. At a median follow-up of 4.8 years (interquartile range, 4.3 to 5.2), a primary-outcome event had occurred in 145 patients (19.0%) in the complete-revascularization group and in 159 patients (20.4%) in the culprit-lesion-only group (hazard ratio, 0.93; 95% confidence interval [CI], 0.74 to 1.17; P = 0.53). With respect to the secondary outcomes, no apparent between-group differences were observed in the composite of death from any cause or myocardial infarction (hazard ratio, 1.12; 95% CI, 0.87 to 1.44) or unplanned revascularization (hazard ratio, 0.76; 95% CI, 0.56 to 1.04). There were no apparent between-group differences in safety outcomes.
Conclusions:
Among patients with STEMI or very-high-risk NSTEMI and multivessel coronary artery disease, FFR-guided complete revascularization was not shown to result in a lower risk of a composite of death from any cause, myocardial infarction, or unplanned revascularization than culprit-lesion-only PCI at 4.8 years. (Funded by the Swedish Research Council and others; FULL REVASC ClinicalTrials.gov number, NCT02862119.).
