Fractional Flow Reserve-guided Complete or Culprit-only PCI in Patients With ST-elevation Myocardial Infarction—Coverage of ACC 2024 | SCAI

Why is this study important?

  • Multivessel coronary artery disease (CAD) is common among patients presenting with acute myocardial infarction (MI).
  • Previous randomized controlled trials (RCTs) have shown the benefit of complete revascularization as compared to the culprit lesion-only approach, however revascularization of non-culprit lesions was guided by angiography.
  • Whether a fractional flow reserve (FFR)-guided strategy of non-culprit lesion revascularization is superior to a culprit lesion-only strategy remains controversial.

 What question was this study supposed to answer?

To compare FFR-guided revascularization of non-culprit lesions and culprit lesion-only revascularization among patients presenting with ST-elevation myocardial infarction (STEMI) or very high-risk Non-ST-elevation myocardial infarction (NSTEMI).

What did the study show?

  • 1,542 patients with STEMI or high-risk NSTEMI who underwent primary percutaneous coronary intervention (PCI) of culprit lesion were randomized to FFR-guided complete revascularization or culprit lesion-only PCI. Patients with previous bypass surgery, left main coronary disease, or cardiogenic shock were excluded.
  • In the complete revascularization group, 60% of the patients had any vessel with an FFR of 0.80 or less and 47% of non-culprit lesions had FFR of 0.80 or less.
  • At median follow-up of 4.8 years, FFR-guided complete revascularization did not reduce the primary outcome of death, MI or unplanned revascularization as compared with culprit lesion-only PCI (19% vs. 20.4%, p= 0.53).
  • Rates of secondary endpoints including death, MI, or unplanned revascularization were also similar in the two arms.

 Key Takeaways:

  • In the FULL REVASC trial, a strategy of FFR-guided complete revascularization was not associated with improved outcomes compared with culprit lesion-only PCI among patients with STEMI or very high-risk NSTEMI and multivessel disease.
  • This is in contrast with results of previous trials showing the benefit of complete revascularization as compared to culprit lesion-only PCI.
  • More studies are needed to ascertain if a physiology-guided approach for complete revascularization improves outcomes among patients with STEMI and multivessel disease. 
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