Fractional flow reserve versus angiography-guided strategy in acute myocardial infarction with multivessel disease: a randomized trial. (20th December 2022)

• Record Type: Journal Article
• Authors: Lee, Joo Myung; Kim, Hyun Kuk; Park, Keun Ho; Choo, Eun Ho; Kim, Chan Joon; Lee, Seung Hun; Kim, Min Chul; Hong, Young Joon; Ahn, Sung Gyun; Doh, Joon-Hyung; Lee, Sang Yeub; Park, Sang Don; Lee, Hyun-Jong; Kang, Min Gyu; Koh, Jin-Sin; Cho, Yun-Kyeong; Nam, Chang-Wook; Koo, Bon-Kwon; Lee, Bong-Ki; Yun, Kyeong Ho; Hong, David; Joh, Hyun Sung; Choi, Ki Hong; Park, Taek Kyu; Yang, Jeong Hoon; Song, Young Bin; Choi, Seung-Hyuk; Gwon, Hyeon-Cheol; Hahn, Joo-Yong
• Is Part Of: European heart journal. Volume 44:Number 6(2023)
• Page Start: 473
• Page End: 484
• Publication Date: 2022-12-20
• Subjects: Acute myocardial infarction -- Percutaneous coronary intervention -- Fractional flow reserve -- Complete revascularization; Cardiology -- Periodicals; Heart -- Diseases -- Periodicals; 616.12005
• DOI: 10.1093/eurheartj/ehac763
• Languages: English
• ISSNs: 0195-668X

Abstract

Abstract: Aims: In patients with acute myocardial infarction (MI) and multivessel coronary artery disease, percutaneous coronary intervention (PCI) of non-infarct-related artery reduces death or MI. However, whether selective PCI guided by fractional flow reserve (FFR) is superior to routine PCI guided by angiography alone is unclear. The current trial sought to compare FFR-guided PCI with angiography-guided PCI for non-infarct-related artery lesions among patients with acute MI and multivessel disease. Methods and results: Patients with acute MI and multivessel coronary artery disease who had undergone successful PCI of the infarct-related artery were randomly assigned to either FFR-guided PCI (FFR ≤0.80) or angiography-guided PCI (diameter stenosis of >50%) for non-infarct-related artery lesions. The primary end point was a composite of time to death, MI, or repeat revascularization. A total of 562 patients underwent randomization. Among them, 60.0% underwent immediate PCI for non-infarct-related artery lesions and 40.0% were treated by a staged procedure during the same hospitalization. PCI was performed for non-infarct-related artery in 64.1% in the FFR-guided PCI group and 97.1% in the angiography-guided PCI group, and resulted in significantly fewer stent used in the FFR-guided PCI group (2.2 ± 1.1 vs. 2.5 ± 0.9, P < 0.001). At a median follow-up of 3.5 years (interquartile range: 2.7–4.1 years), the primary end point occurred in 18 patients of 284 patients in the FFR-guided PCI group and in 40 of 278 patients in the angiography-guided PCI group (7.4% vs. 19.7%; hazard ratio, 0.43; 95% confidence interval, 0.25–0.75; P = 0.003). The death occurred in five patients (2.1%) in the FFR-guided PCI group and in 16 patients (8.5%) in the angiography-guided PCI group; MI in seven (2.5%) and 21 (8.9%), respectively; and unplanned revascularization in 10 (4.3%) and 16 (9.0%), respectively. Conclusion: In patients with acute MI and multivessel coronary artery disease, a strategy of selective PCI using FFR-guided decision-making was superior to a strategy of routine PCI based on angiographic diameter stenosis for treatment of non-infarct-related artery lesions regarding the risk of death, MI, or repeat revascularization. Structured Graphical Abstract: Structured Graphical Abstract Although findings of previous randomized trials suggest a complete revascularization strategy is beneficial than IRA-only PCI, it is still unclarified regarding which non-IRA lesions should be revascularized. The FRAME-AMI trial showed that FFR-guided PCI reduced a composite of death, MI, or repeat revascularization at a median follow-up of 3.5 years compared with angiography-guided PCI for the treatment of non-IRA lesions in patients with AMI and multivessel disease. This reduction was driven mainly by a significantly lower risk of death and MI in the FFR-guided PCI group. Moreover, fewer stents and fewer contrast media were used with FFR-guided PCI than with angiography-guided PCI. The findings of our trial shed light on the efficacy and safety of doing selective PCI of non-IRA lesions using FFR-guided decision-making would provide fewer stents needed and fewer contrast media use, and significantly lower risk of adverse clinical events after PCI, compared with a strategy of routine PCI based on angiographic diameter stenosis in non-IRA.