Comparison Between FFR Guided Revascularization Versus Conventional Strategy in Acute STEMI Patients With MVD. (CompareAcute)

Fractional Flow Reserve Guided Primary Multivessel Percutaneous Coronary Intervention to Improve Guideline Indexed Actual Standard of Care for Treatment of ST-elevation Myocardial Infarction in Patients With Multivessel Coronary Disease

The Compare-Acute trial is a prospective randomised trial in patients with multivessel disease, who are admitted into hospital with a ST-elevation Myocardial Infarction. The purpose of the study is to compare a FFR guided multivessel PCI taking place during the primary PCI with a primary PCI of the culprit vessel only.

Patients will be enrolled after successful revascularisation of the culprit vessel. Patients that have at least one lesion with a diameter of stenosis of more than 50% on visual estimation, feasible (operators judgement) for treatment with PCI in a non-infarct related artery, will be randomised either to the FFR guided complete revascularisation arm or staged revascularisation by proven ischemia or persistence of symptoms of angina.

Approximately 885 patients will be entered in the study.

Study hypothesis: FFR-guided complete percutaneous revascularisation of all flow-limiting stenoses in the non-IRA performed within the same procedure as the primary PCI or within the same hospitalisation will improve clinical outcomes compared to the staged revascularisation, guided by prove of ischemia or clinical judgment, as recommended from the guidelines.

Study Overview

• Status: Completed
• Conditions: Myocardial Infarction; Multivessel Coronary Artery Disease
• Intervention / Treatment: Procedure: FFR-guided revascularisation strategy; Procedure: randomised to guidelines group

Detailed Description

Background of the study: At the moment the general opinion is divided over the way the non culprit lesions in patients presenting with STEMI should be treated. While the previous guidelines stead that these lesions should be treated in a second time ( ie not during the primary intervention) the actual guidelines do not touch this argument. The reason is that the studies where the previous guidelines were based are old. Meanwhile small sized randomised trials from EU region have proven favourable outcomes with NON infarct related artery during the primary procedure while registers (non randomised trials) from USA still recommend the staged treatment. For this reason we have decided to perform a randomised study to address this issue incorporating the state of the art diagnosis and treatment, as well as the new medical therapy and PCI techniques.

Objective of the study: FFR-guided complete percutaneous revascularisation of all flow-limiting stenoses in the non-IRA performed within the same procedure as the primary PCI or within the same hospitalisation will improve clinical outcomes compared to the staged revascularisation, guided by prove of ischemia or clinical judgment, as recommended from the guidelines

Study design: Prospective, 1: 2 randomisation. FFR guided revascularisation during primary PCI (1) versus following actual guidelines (2)

Study population: All STEMI patients between 18-85 years who will be treated with primary PCI in < 12 h (more than 12 hr if persisting pain allowed) after the onset of symptoms and have at least one stenosis of >50% in a non-IRA judged feasible for treatment with PCI.

Intervention (if applicable): FFR-guided complete percutaneous revascularisation of all flow-limiting stenoses in the non-IRA performed within the same procedure as the primary PCI or within the same hospitalisation will improve clinical outcomes compared to the staged revascularisation, guided by prove of ischemia or clinical judgment, as recommended from the guidelines

Primary study parameters/outcome of the study: Composite endpoint of all cause mortality non-fatal Myocardial Infarction, any Revascularisation and Stroke (MACCE) at 12 months

• Study Type: Interventional
• Enrollment (Actual): 885
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Czechia
  • Brno, Czechia
    • University Hospital Brno
  • Hradec Králové, Czechia
    • University hospital Hradec Králové
  • Liberec, Czechia
    • Liberec Regional Hospital
• Germany
  • Bad Krozingen, Germany, 79189
    • Herz-Zentrum Bad Krozingen
  • Bad Segeberg, Germany, 23795
    • Herzzentrum Bad Segeberger Klinik
  • Bremen, Germany, 28277
    • Klinikum Links der Weser
  • Ingolstadt, Germany, 85049
    • Medizinische Klinik IV
  • Rostock, Germany, 18057
    • Medical University Rostock
• Hungary
  • Budapest, Hungary
    • Gottsegen György Országos Kardiológiai Intézet
  • Nyíregyháza, Hungary
    • Szabolcs - Szatmár - Bereg County Hospitals and University Teaching Hospital
  • Szeged, Hungary
    • Szent-Györgyi Albert Klinika
  • Zalaegerszeg, Hungary
    • Zala Megyei Kórház
• Netherlands
  • Arnhem, Netherlands
    • Rijnstate Hospital
  • Groningen, Netherlands
    • University Medical Center Groningen
  • Heerlen, Netherlands
    • Atrium MC Parkstad
  • Maastricht, Netherlands
    • Maastricht Universitair Medical center
  • Rotterdam, Netherlands, 3079DZ
    • Maasstadhospital
  • The Hague, Netherlands, 2512 VA
    • Medisch Centrum Haaglanden
• Norway
  • Oslo, Norway
    • Oslo University Hospital
• Poland
  • Lubin, Poland
    • Miedziowe Centrum Zdrowia Lubin
  • Warsaw, Poland
    • Centralny Szpital Kliniczny MSWiA w Warszawie
  • Warsaw, Poland
    • Kliniki Kardiologii Allenort
  • Wroclaw, Poland
    • 4 Wojskowy Szpital Kliniczny Z Poliklinika SP ZOZ
• Singapore
  • Singapore, Singapore, 308433
    • Tan Tock Seng Hospital
  • Singapore, Singapore, 768828
    • Khoo Teck Puat Hospital
• Sweden
  • Goteborg, Sweden, 41315
    • Sahlgrenska Götheborg University Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 85 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• All patients between 18-85 years presenting with STEMI who will be treated with primary PCI in < 12 h after the onset of symptoms* and have at least one stenosis of >50% in a non-IRA on QCA or visual estimation of baseline angiography and judged feasible for treatment with PCI by the operator.

  • Patients with symptoms for more than 12 hr but ongoing angina complaints can be randomised

Exclusion Criteria:

1. Left main stem disease (stenosis > 50%)
2. STEMI due to in-stent thrombosis
3. Chronic total occlusion of a non-IRA
4. Severe stenosis with TIMI flow ≤ II of the non-IRA artery.
5. Non-IRA stenosis not amenable for PCI treatment (operators decision)

6. Complicated IRA treatment, with one or more of the following;

   • Extravasation,
   • Permanent no re-flow after IRA treatment (TIMI flow 0-1),
   • Inability to implant a stent
7. Known severe cardiac valve dysfunction that will require surgery in the follow-up period.
8. Killip class III or IV already at presentation or at the completion of culprit lesion treatment.
9. Life expectancy of < 2 years.
10. Intolerance to Aspirin, Clopidogrel, Prasugrel, Ticagrelor, Heparin, Bivaluridin, or Everolimus and known true anaphylaxis to prior contrast media of bleeding diathesis or known coagulopathy.
11. Gastrointestinal or genitourinary bleeding within the prior 3 months,
12. Planned elective surgical procedure necessitating interruption of thienopyridines during the first 6 months post enrolment.
13. Patients who are actively participating in another drug or device investigational study, which have not completed the primary endpoint follow-up period.
14. Pregnancy or planning to become pregnant any time after enrolment into this study.
15. Inability to obtain informed consent.
16. Expected lost to follow-up.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: FFR-guided revascularisation strategy; In the FFR-group all flow limiting (FFR≤0.80) lesions will receive treatment by PCI and stenting. The non-IRA PCI should be performed during the same intervention. Exceptions can be made for complex lesions where the operator estimates that the revascularisation procedure will require significant contrast overload which may lead to deterioration of cardiac and renal function of the patient. Such procedures can be performed in a second procedure which should take place within the same hospitalisation. All lesions with a FFR measurement of >0.80 will not be treated.	Procedure: FFR-guided revascularisation strategy; FFR-guided revascularisation strategy
Placebo Comparator: randomised to guidelines group; In the randomised to guidelines group the procedure will stop after the FFR measurements and the patient will be referred to his treating cardiologist who will decide whether a staged PCI of the non-IRA artery should take place. The treating cardiologist will be blinded for the FFR measurements (but not angiographic imaging) and must make a decision based on conventional non-invasive ischemia detecting tests or clinical signs and symptoms i.e. very typical angina symptoms in patients with angiographic significant stenosis).	Procedure: randomised to guidelines group; Staged revascularisation by proven ischemia or persistence of symptoms of angina

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Participants With the Composite Endpoint of MACCE	Number of participants with the composite endpoint of all cause mortality non-fatal Myocardial Infarction, any Revascularisation and Cerebrovascular Events (MACCE) at 12 months between groups	12 months
Number of Participants With Death From Any Cause	Number of participants with all cause mortality at 12 months between groups	12 months
Number of Participants With Cardiac Death	Number of participants with Cardiac mortality at 12 months between groups	12 months
Number of Participants With Spontaneous MI	Number of participants with Spontaneous Myocardial Infarction at 12 months between groups	12 months
Number of Participants With Periprocedural MI	Number of participants with Periprocedural Myocardial Infarction at 12 months between groups	12 months
Number of Participants With Revascularization - PCI	Number of participants with revascularization PCI at 12 months between groups	12 months
Number of Participants With Revascularization - CABG	Number of participants with revascularization CABG at 12 months between groups	12 months
Number of Participants With Cerebrovascular Event	Number of participants with Cerebrovascular event at 12 months between groups	12 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Participants With Composite Endpoint of NACE (Any First Event)	Number of participants with Composite endpoint of Cardiac death, Myocardial Infarction, any Revascularisation, Stroke and Major bleeding at 12 months (NACE i.e. Net Adverse Clinical Events)	12 months
Number of Participants With Death From Any Cause or MI	Number of participants with Part of composite NACE-Death from any cause or Myocardial Infarction at 12 months	12 months
Number of Participants With Major Bleeding	Number of participants with Major bleeding at 12 months - Part of composite NACE	12 months
Number of Participants With Any Bleeding at 12 Months	Number of participants with any bleeding at 12 months - part of composite endpoint NACE	12 months
Number of Participants With Any Bleeding at 48 Hours	Number of participants with any bleeding at 48 hours - part of composite endpoint NACE	48 hours
Number of Participants With Hospitalization	Number of participants with hospitalization for heart failure, unstable angina or chest pain	12 months
Number of Participants With Revascularization	Number of participants with any revascularization-Part of composite endpoint NACE	12 months
Number of Participants With Stent Thrombosis	Number of participants with Stent Thrombosis - Part of composite endpoint NACE	12 months
Number of Participants With Primary Endpoint Outcome MACCE (Any First Event) at 3 Year	Number of participants with Composite primary endpoint MACCE (any first event) at 3 year	3 year
Number of Participants With All Cause Death at 3 Year	Number of participants with Composite endpoint MACCE (any first event) at 3 year - all cause death	3 year
Number of Participants With Cardiac Death at 3 Year	Number of participants with Composite endpoint MACCE (any first event) at 3 year - Cardiac death	3 year
Number of Participants With Spontaneous MI at 3 Year	Number of participants with Composite endpoint MACCE (any first event) at 3 year - Spontaneous MI	3 year
Number of Participants With Peri-procedural MI at 3 Year	Number of participants with Composite endpoint MACCE (any first event) at 3 year - Peri-procedural MI	3 year
Number of Participants With Urgent Revascularization at 3 Year	Number of participants with Composite endpoint MACCE (any first event) at 3 year - urgent revascularisation	3 year
Number of Participants With Elective Revascularization at 3 Year	Number of participants with Composite endpoint MACCE (any first event) at 3 year -elective revascularisation	3 year
Number of Participants With Cerebrovascular Event	Number of participants with Composite endpoint MACCE (any first event) at 3 year -Cerebrovascular event	3 year
Number of Participants With Composite Endpoint of NACE (Any First Event) at 3 Year	Number of participants with Composite endpoint of Cardiac death, Myocardial Infarction, any Revascularisation, Stroke and Major bleeding at 3 year (NACE i.e. Net Adverse Clinical Events)	3 years
Number of Participants With Death From Any Cause or MI	Number of participants with Part of composite NACE-Death from any cause or Myocardial Infarction at 3 year	3 year
Number of Participants With Major Bleeding at 3 Year	Number of participants with Part of composite endpoint NACE- Major bleeding at 3 year	3 year
Number of Participants With Hospitalization	Number of participants with Hospitalization for heart failure, unstable angina, MI	3 year
Number of Participants With Hospitalization at 3 Year	Number of participants with Hospitalization for heart failure, unstable angina, MI and/or chest pain	3 year
Number of Participants With Stent Thrombosis at 3 Year	Number of participants with Stent Thrombosis at 3 year - Part of composite endpoint NACE	3 year
Number of Participants With Any Bleeding at 3 Year	Number of participants with any bleeding at 3 year - Part of composite endpoint NACE	3 year

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
A Comparison of the Number of Patients in Both Groups With Treated Lesions With FFR ≤ 0.80 Versus Patients With Untreated Lesions With FFR ≤ 0.80;	FFR+/PCI+ vs FFR+/PCI- Comparison of patients having FFR positive lesions that underwent revascularization during index procedure or in staged procedures within 45 days (groups A+C, n=202 patients) with patients having FFR positive lesions that did not undergo revascularization (group D, n=231 patients),	3 year
Comparison of Acute Versus Staged PCI for Lesions With FFR ≤ 0.80	Comparison of acute versus staged PCI treatment for lesions with FFR	3 year
Comparison of PCI vs Medical Therapy in FFR Negative Lesions	comparison of patients receiving staged PCI treatment of FFR-negative lesions in the non-IRA (decision made by referring physician who was blinded to FFR results) and patients receiving medical therapy for FFR-negative lesions in the non-IRA	3 year

Collaborators and Investigators

• Sponsor: Maasstad Hospital
• Collaborators: Abbott Medical Devices
• Investigators: Principal Investigator: Peter Smits, MD. PHD, Maastadhospital / MCR; Study Chair: Elmir Omerovic, MD PhD, Sahlgrenska Hospital Götheborg; Study Chair: Gert Richardt, MD PhD, Herzzentrum Segeberger Kliniken; Study Chair: Franz-Josef Neumann, MD PhD, Herz-Zentrum Bad Krozingen

Publications and helpful links

General Publications

• Wang LJ, Han S, Zhang XH, Jin YZ. Fractional flow reserve-guided complete revascularization versus culprit-only revascularization in acute ST-segment elevation myocardial infarction and multi-vessel disease patients: a meta-analysis and systematic review. BMC Cardiovasc Disord. 2019 Mar 1;19(1):49. doi: 10.1186/s12872-019-1022-6.
• Piroth Z, Fulop G, Boxma-de Klerk BM, Abdelghani M, Omerovic E, Andreka P, Fontos G, Neumann FJ, Richardt G, Smits PC. Correlation and Relative Prognostic Value of Fractional Flow Reserve and Pd/Pa of Nonculprit Lesions in ST-Segment-Elevation Myocardial Infarction. Circ Cardiovasc Interv. 2022 Feb;15(2):e010796. doi: 10.1161/CIRCINTERVENTIONS.121.010796. Epub 2022 Jan 20.
• Smits PC, Abdel-Wahab M, Neumann FJ, Boxma-de Klerk BM, Lunde K, Schotborgh CE, Piroth Z, Horak D, Wlodarczak A, Ong PJ, Hambrecht R, Angeras O, Richardt G, Omerovic E; Compare-Acute Investigators. Fractional Flow Reserve-Guided Multivessel Angioplasty in Myocardial Infarction. N Engl J Med. 2017 Mar 30;376(13):1234-1244. doi: 10.1056/NEJMoa1701067. Epub 2017 Mar 18.

Study record dates

Study Major Dates

• Study Start: July 1, 2011
• Primary Completion (Actual): October 31, 2016
• Study Completion (Actual): October 31, 2018

Study Registration Dates

• First Submitted: July 20, 2011
• First Submitted That Met QC Criteria: July 21, 2011
• First Posted (Estimate): July 22, 2011

Study Record Updates

• Last Update Posted (Actual): August 11, 2020
• Last Update Submitted That Met QC Criteria: July 31, 2020
• Last Verified: May 1, 2020

More Information

Terms related to this study

• Keywords: PCI FFR STEMI MVD; FFR guided PCI in acute STEMI patients with MVD
• Additional Relevant MeSH Terms: Ischemia; Pathologic Processes; Necrosis; Myocardial Ischemia; Heart Diseases; Cardiovascular Diseases; Vascular Diseases; Arteriosclerosis; Arterial Occlusive Diseases; Coronary Disease; Myocardial Infarction; Infarction; Coronary Artery Disease
• Other Study ID Numbers: Compare-Acute

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO