"FFR-Guided PCI in ST-Segment Elevation Myocardial Infarction".The New England Journal of Medicine. Letters to the Editor.
Links to original sources: Wiki Journal Post Full Journal Article
Does fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) of non–infarct-related coronary arteries improve outcomes in patients with ST-segment elevation myocardial infarction (STEMI) compared to treating the infarct-related artery only?
FFR-guided complete revascularization during primary PCI for STEMI was associated with reduced risk of composite primary outcome at 12 months, driven predominantly by lower rates of repeat revascularization compared to a strategy of treating the infarct-related artery alone.
The Compare-Acute trial found benefits in the composite primary outcome with FFR-guided complete revascularization in STEMI patients, but this was mainly due to a reduction in repeat revascularization. When considering revascularizations during the index admission, the difference in total revascularizations between complete-revascularization and infarct-artery-only groups was significant. The trial was not powered to assess single hard end points like myocardial infarction and death.
Current guidelines on the specific use of FFR-guided PCI in STEMI patients during primary PCI for non–infarct-related arteries remain to be updated to reflect results from trials like Compare-Acute.
- Perspective by Drs. Bibas and Thanassoulis questioning interpretation of Compare-Acute trial results. - Response by Drs. Smits and Boxma-de Klerk defending their trial's conclusions and methodology.
- Patients with STEMI undergoing PCI - Not specified in the letters: Full trial inclusion/exclusion criteria from the original Compare-Acute study
- Complete revascularization with FFR-guided PCI of non–infarct-related coronary arteries - Infarct-related artery treatment only
- Bibas and Thanassoulis: Challenge the interpretation of reduced repeat revascularizations. - Ferrante and Stefanini: Point out potential for operator bias and misclassification of events in the infarct-artery-only group. - Authors Smits and Boxma-de Klerk: Defend results, highlighting post hoc analyses that continue to show reduced MACCE with the complete-revascularization strategy despite potential operator bias.
- Drs. Bibas and Thanassoulis argued that the study could be interpreted differently, suggesting more total revascularizations in complete-revascularization group when including index admission procedures, advocating for trials powered to assess hard clinical outcomes excluding revascularization. - Drs. Ferrante and Stefanini suggested a risk of misclassification of events, potentially leading to a falsely optimistic view of treatment effects.
Not specified in the letters. The original Compare-Acute trial funding should be referred to for more details.
- Original Compare-Acute trial publication and supplementary materials. - Further trials evaluating the role of FFR-guided complete revascularization in STEMI patients.
References 1. Smits PC, et al. Fractional Flow Reserve-Guided Multivessel Angioplasty in Myocardial Infarction. N Engl J Med. 2017;376:1234-1244. 2. Original letters and response in The New England Journal of Medicine.