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"FFR-Guided PCI in ST-Segment Elevation Myocardial Infarction".The New England Journal of Medicine. Letters to the Editor.

Clinical Question

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?

Bottom Line

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.

Major Points

Guidelines

Design

- Response by Drs. Smits and Boxma-de Klerk defending their trial's conclusions and methodology.

Population

- Patients with STEMI undergoing PCI

Interventions

- Complete revascularization with FFR-guided PCI of non–infarct-related coronary arteries
- Infarct-related artery treatment only

Outcomes

- 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.

Criticisms

- Drs. Bibas and Thanassoulis argued that the study could be interpreted differently, suggesting more total revascularizations in complete-revascularization group when including index_gpt 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.