Revascularization Strategies in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Disease: Is FFR-Guided Strategy Still Valuable?

Doosup Shin, Tae-Min Rhee, Seung Hun Lee, Joo Myung Lee, Doosup Shin, Tae-Min Rhee, Seung Hun Lee, Joo Myung Lee

Abstract

Several studies have shown the benefit of complete revascularization (CR) over culprit-only percutaneous coronary intervention (PCI) in patients with ST-segment elevated myocardial infarction (STEMI) and multivessel disease (MVD). Nevertheless, optimal strategy to select targets for non-culprit PCI has not been clarified. In this paper, we critically discuss and compare the safety and efficacy of different strategies for CR in patients with STEMI and MVD using a Bayesian network meta-analysis including all previous randomized controlled trials (RCTs). In Bayesian network meta-analysis of 13 RCTs, culprit-only PCI was associated with higher risk of major adverse cardiac events (MACE), compared with angiography-guided or fractional flow reserve (FFR)-guided CR strategies. However, there was no significant difference between angiography-guided and FFR-guided CR strategies in the risk of MACE and its individual components including all-cause death, cardiac death, myocardial infarction (MI), and revascularization. These evidence support that both angiography-guided and FFR-guided complete revascularization strategies would be reasonable treatment option in patients with STEMI and MVD. If the non-culprit lesion is severe on visual assessment, angiography-guided PCI can be considered. If the non-culprit lesion is intermediate in severity or unclear based on visual assessment, FFR-guided strategy can be used as a reliable and objective tool, providing similar benefits with less stents compared with an angiography-guided strategy. Further RCT is needed to evaluate direct comparison between angiography-guided and FFR-guided CR strategies in patients with STEMI and MVD. Ongoing FRAME-AMI trial (NCT02715518) will provide more evidence regarding this issue.

Keywords: Acute myocardial infarction; Fractional flow reserve; Meta-analysis; Percutaneous coronary intervention; ST-segment elevation myocardial infarction.

Conflict of interest statement

The authors have no financial conflicts of interest.

Copyright © 2022. The Korean Society of Cardiology.

Figures

Figure 1. Network meta-analysis comparing culprit-only PCI,…
Figure 1. Network meta-analysis comparing culprit-only PCI, FFR-guided, and angiography-guided CR.
(A-F) Results from network meta-analysis using the Bayesian extension of the hierarchical random-effects model are presented. ACS = acute coronary syndrome; Angio-CR = angiography-guided complete revascularization; Culprit-only = culprit-only percutaneous coronary intervention; CR = complete revascularization; CrI = credible interval; CVA = cerebrovascular accident; DM = diabetes mellitus; DS = diameter stenosis; EF = ejection fraction; FFR = fractional flow reserve; FFR-CR = fractional flow reserve-guided complete revascularization; HF = heart failure; ID = ischemia-driven; MI = myocardial infarction; NR = not reported; QCA = quantitative coronary angiography; RR = repeat revascularization; VD = vessel disease.

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Source: PubMed

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