FFR-Guided Complete Revascularization Beneficial in NSTEMI With Multivessel Disease: JAMA
RPGMC-Tanda’s Road to PGIMER
Netherlands: Researchers have found in a new study that fractional flow reserve-guided complete revascularization during the index procedure is effective for patients with non-ST-segment elevation myocardial infarction (NSTEMI) and multivessel disease.
The trial, published in JAMA and led by Dr. Tobias F.S. Pustjens from the Department of Cardiology at Zuyderland Medical Centre, the Netherlands, provides important clinical evidence on the benefits of treating all significant coronary lesions, rather than focusing solely on the culprit artery, in patients with NSTEMI.
The SLIM (Fractional Flow Reserve–Guided Complete Versus Culprit-Only Revascularization in NSTEMI and Multivessel Disease) randomized clinical trial included 478 patients across nine European hospitals. Participants had a mean age of nearly 66 years, and more than 70% were men. All patients underwent successful treatment of the culprit lesion and were then randomized to either FFR-guided complete revascularization or culprit-only revascularization, with staged procedures allowed in the culprit-only group.
Based on the study, the researchers reported the following findings:
- The primary composite outcome of all-cause mortality, nonfatal myocardial infarction, any revascularization, and stroke within one year occurred in 5.5% of patients in the complete revascularization group versus 13.6% in the culprit-only group.
- This corresponded to a 62% relative risk reduction (HR, 0.38).
- The difference was mainly driven by lower rates of repeat revascularization in the complete revascularization arm (3.0% vs 11.5%; HR, 0.24).
- Net adverse clinical events were also significantly reduced (6.3% vs 15.3%; HR, 0.39).
- No significant differences were observed in individual outcomes such as death or myocardial infarction when analyzed separately.
According to the authors, these findings suggest that addressing all physiologically significant lesions in a single setting can improve outcomes and reduce the need for future interventions. The results lend support to adopting an FFR-guided complete revascularization approach in NSTEMI patients with multivessel disease.
Still, the study had several limitations. It was not sufficiently powered to detect differences in individual outcomes such as cardiovascular death or myocardial infarction, which are being further explored in the ongoing COMPLETE-NSTEMI trial. The open-label design could have influenced treatment decisions in the culprit-only group, and the absence of data on patients who were screened but not enrolled raises concerns about selection bias. Additionally, identifying the culprit lesion in NSTEMI can be complex, and the definition of significant stenosis at a 50% threshold may vary across clinical practices.
Despite these challenges, the investigators concluded that FFR-guided complete revascularization provides meaningful clinical benefit in reducing composite cardiovascular events. The advantage was mainly driven by fewer repeat procedures, highlighting the value of treating all significant lesions upfront.
"The SLIM trial contributes to evolving evidence in the management of NSTEMI with multivessel disease, offering important insights for clinicians weighing complete versus selective intervention strategies," the authors concluded.
Reference:
Pustjens TF, Veenstra L, Camaro C, et al. Fractional Flow Reserve–Guided Complete vs Culprit-Only Revascularization in Non–ST-Elevation Myocardial Infarction and Multivessel Disease: The SLIM Randomized Clinical Trial. JAMA. Published online August 31, 2025. doi:10.1001/jama.2025.16189
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