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10-year outcome of fractional flow reserve-guided complete revascularization in patients with ST-segment elevation
Utsho Islam1, Jasmine M Marquard1, Ibrahim M A Khalek1
1The Heart Center, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
Insights
Deferring percutaneous coronary intervention (PCI) for non-culprit lesions in ST-segment elevation myocardial infarction (STEMI) patients with FFR >0.80 increased risks of mortality and myocardial infarction. Complete revascularization with PCI improved long-term outcomes.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Clinical Trials
Background:
- Complete revascularization is recommended for ST-segment elevation myocardial infarction (STEMI) with multivessel disease.
- Optimal strategy for non-culprit lesions (angiography vs. fractional flow reserve [FFR]) is uncertain.
- This study evaluates long-term outcomes of deferred PCI for non-culprit lesions with FFR >0.80 in STEMI patients.
Purpose of the Study:
- To assess the long-term clinical outcomes of patients with STEMI and multivessel disease who deferred percutaneous coronary intervention (PCI) for non-culprit lesions with fractional flow reserve (FFR) >0.80.
- To compare outcomes between PCI-deferral and PCI groups for non-culprit lesions.
Main Methods:
- Substudy of 314 patients from the DANAMI-3-PRIMULTI trial.
- Patients divided into PCI-deferral (n=106, FFR >0.80) and PCI (n=174, FFR ≤0.80 or ≥90% stenosis) groups.
- Combined endpoint: all-cause mortality, myocardial infarction, or urgent revascularization.
Main Results:
- Median follow-up of 10.5 years.
- Composite outcome occurred in 47% of PCI-deferral vs. 36% of PCI group (adjusted HR 0.64, p=0.025).
- PCI-deferral associated with higher cardiovascular mortality risk (adjusted HR 0.48, p=0.040).
Conclusions:
- Deferring PCI for non-culprit lesions (FFR >0.80) in STEMI patients increases risks of mortality, MI, and urgent revascularization.
- PCI of FFR-positive non-culprit lesions is associated with better long-term outcomes.
- FFR guidance is crucial for optimizing revascularization strategy in STEMI with multivessel disease.
Background:
Complete revascularization is recommended in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease. However, whether the non-culprit lesions should be evaluated using angiography or fractional flow reserve (FFR) remains uncertain. The aim of this study was to evaluate the long-term outcome of patients with STEMI and multivessel disease who had non-culprit FFR-values >0.80 and thus deferred PCI.
Methods:
Of the 627 patients included in the DANAMI-3-PRIMULTI trial, 314 patients were randomized to FFR-guided complete revascularization and 280 were included in this substudy. Patients were divided into a PCI-deferral group who had no PCI of non-culprit lesions (FFR > 0.80) (n = 106) and a PCI group encompassing patients treated with PCI of at least one non-culprit lesion (FFR ≤ 0.80 or an angiographical diameter stenosis of ≥90%) (n = 174). The combined endpoint included all-cause mortality, myocardial infarction, or urgent revascularization.
Results:
During a median follow-up of 10.5 years (IQR 9.8-11.4), the composite outcome occurred in 62 (36%) patients in the PCI group and in 50 (47%) patients in the PCI-deferral group (adjusted HR 0.64, 95% CI: 0.44-0.95, p = 0.025). PCI-deferral was associated with a significantly higher risk of cardiovascular mortality (adjusted HR 0.48, CI 95% 0.24-0.97, p = 0.040) compared to the PCI group.
Conclusion:
In patients with STEMI and multivessel disease, deferring PCI of non-culprit lesions based on FFR > 0.80 was associated with an increased risk of the combination of all-cause mortality, myocardial infarction, or urgent revascularization as well as cardiovascular mortality compared to patients treated with PCI of FFR-positive non-culprit lesions.
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