Fractional flow reserve superior to angiography-guided strategy in acute MI with multivessel CAD: Study

The study found that in the study population, a strategy of selective PCI using FFR-guided decision-making is superior to a routine PCI (percutaneous coronary intervention) based on angiographic diameter stenosis for treating non-infarct-related artery lesions concerning the risk of myocardial infarction, death, or repeat revascularization.

In patients with acute MI and multivessel coronary artery disease, PCI of non-infarct-related arteries reduces MI or death. However, there needs to be more clarity on whether selective PCI guided by FFR is superior to PCI guided by angiography alone. Therefore, Joo Myung Lee from Sungkyunkwan University School of Medicine in Seoul, Korea, and colleagues compared FFR-guided PCI with angiography-guided PCI for non-infarct-related artery lesions in patients with acute MI and multivessel disease.

The trial included patients with acute MI and multivessel CAD who had undergone successful PCI of the infarct-related artery. They were randomly assigned to either angiography-guided PCI (diameter stenosis of more than 50%) or FFR-guided PCI (FFR ≤0.80) for non-infarct-related artery lesions. A composite of time to death, repeat revascularization, or MI (primary endpoint) was determined.

The study led to the following findings:

• A total of 562 patients underwent randomization. Among them, 60.0% underwent immediate PCI for non-infarct-related artery lesions, and a staged procedure treated 40.0% during the same hospitalization.
• PCI was performed for non-infarct-related arteries in 64.1% of the FFR-guided PCI group and 97.1% in the angiography-guided PCI group, resulting in significantly fewer stents used in the FFR-guided PCI group (2.2 ± 1.1 vs. 2.5 ± 0.9).
• At a median follow-up of 3.5 years, the primary endpoint occurred in 18 patients of 284 patients in the FFR-guided PCI group and 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 2.1% of patients in the FFR-guided PCI group and 8.5% of patients in the angiography-guided PCI group; MI in 2.5% and 8.9%, respectively; and unplanned revascularization in 4.3% and 9.0%, respectively.

The trial's findings shed light on the safety and efficacy of performing selective PCI of non-IRA lesions using FFR-guided decision-making would provide fewer stents needed and fewer use of contrast media, and remarkably lower risk of adverse clinical events following PCI, compared with a strategy of routine PCI based on angiographic diameter stenosis in non-IRA.

"The decision to perform angioplasty on non-culprit lesions was better guided by fractional flow reserve for patients with acute myocardial infarction than by angiographic diameter stenosis," the authors concluded.

Reference:

Joo Myung Lee, Hyun Kuk Kim, Keun Ho Park, Eun Ho Choo, Chan Joon Kim, Seung Hun Lee, Min Chul Kim, Young Joon Hong, Sung Gyun Ahn, Joon-Hyung Doh, Sang Yeub Lee, Sang Don Park, Hyun-Jong Lee, Min Gyu Kang, Jin-Sin Koh, Yun-Kyeong Cho, Chang-Wook Nam, Bon-Kwon Koo, Bong-Ki Lee, Kyeong Ho Yun, David Hong, Hyun Sung Joh, Ki Hong Choi, Taek Kyu Park, Jeong Hoon Yang, Young Bin Song, Seung-Hyuk Choi, Hyeon-Cheol Gwon, Joo-Yong Hahn, The FRAME-AMI Investigators, Fractional flow reserve versus angiography-guided strategy in acute myocardial infarction with multivessel disease: a randomized trial, European Heart Journal, 2022;, ehac763, https://doi.org/10.1093/eurheartj/ehac763