FFR-Guided Complete Revascularization Evaluated in Patients With STEMI and Severe Nonculprit Disease

April 17, 2017—A substudy of the DANAMI-3–PRIMULTI trial demonstrated that fractional flow reserve (FFR)-guided complete revascularization improves the prognosis in patients with ST-segment elevation myocardial infarction (STEMI) and severe nonculprit disease. The findings were published online ahead of print by Jacob Lønborg, MD, et al in Circulation: Cardiovascular Interventions. DANAMI-3–PRIMULTI is the Danish Acute Myocardial Infarction trial of primary percutaneous coronary intervention (PCI) in patients with STEMI and multivessel disease, which is evaluating treatment of culprit lesion only or complete revascularization.

The objective of this post hoc study was to evaluate the impact of the number of diseased vessels, lesion location, and severity of the noninfarct-related stenosis on the effect of FFR-guided complete revascularization.

As summarized in Circulation: Cardiovascular Interventions, the DANAMI-3–PRIMULTI investigators randomized 627 STEMI patients to FFR-guided complete revascularization or infarct-related PCI only.

In patients with three-vessel disease, FFR-guided complete revascularization reduced the primary endpoint of all-cause mortality, reinfarction, and ischemia-driven revascularization (hazard ratio [HR], 0.33; 95% confidence interval [CI], 0.17–0.64; P = .001); with no significant effect in patients with two-vessel disease (HR, 0.77; 95% CI, 0.47–1.26; P = .29; P for interaction = .046). 

A similar effect was observed in patients with diameter stenosis ≥ 90% of noninfarct-related arteries (HR, 0.32; 95% CI, 0.18–0.62; P = .001), but not in patients with less severe lesions (HR, 0.72; 95% CI, 0.44–1.19; P = .21; P for interaction = .06).

The effect was most pronounced in patients with three-vessel disease and noninfarct-related stenoses ≥ 90%. In this subgroup, there was a nonsignificant reduction in the endpoint of mortality and reinfarction (HR, 0.32; 95% CI, 0.08–1.32; P = .09). Proximal versus distal location did not influence the benefit from complete revascularization.

The benefit from FFR-guided complete revascularization in STEMI patients with multivessel disease was dependent on the presence of three-vessel disease and noninfarct diameter stenosis ≥ 90% and was particularly pronounced in patients with both of these angiographic characteristics, concluded the investigators in Circulation: Cardiovascular Interventions.