The New England Journal of MedicineFFR-Guided Complete or Culprit-Only PCI in Patients with Myocardial Infarction

Comparative Efficacy of FFR-Guided Revascularization in Multivessel Coronary Intervention

In an era where tailored treatment approaches are increasingly valued, the latest multinational, registry-based, randomized trial explores the efficacy of fractional flow reserve (FFR)–guided complete revascularization versus culprit-lesion-only percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease. This study aims to clarify the optimal strategy for managing nonculprit lesions in a high-risk cardiac patient population.

Study Design:

• Population: The study enrolled 1,542 patients with STEMI or very-high-risk non-STEMI (NSTEMI) who also presented with multivessel coronary artery disease.
• Intervention: Participants were randomly assigned to undergo either FFR-guided complete revascularization of nonculprit lesions or no further revascularization beyond the initial culprit lesion PCI.
• Follow-up Duration: The median follow-up period was 4.8 years, with an interquartile range from 4.3 to 5.2 years.
• Study Type: Multinational, registry-based, randomized trial.

Key Findings:

• Primary Outcome: The primary composite outcome of death from any cause, myocardial infarction, or unplanned revascularization occurred in 19.0% of the complete-revascularization group compared to 20.4% of the culprit-lesion-only group (hazard ratio, 0.93; 95% CI, 0.74 to 1.17; P=0.53).
• Secondary Outcomes: There were no significant differences between the two groups in the rates of death from any cause or myocardial infarction, nor in unplanned revascularizations.
• Safety Outcomes: No significant between-group differences were noted in terms of safety.

HCN Medical Memo
Although FFR-guided revascularization remains a cornerstone in managing coronary artery disease, this study suggests that in the context of STEMI or high-risk NSTEMI with multivessel involvement, the additional intervention beyond the culprit lesion does not significantly alter long-term outcomes. These insights should guide physicians in making more informed decisions regarding the extent of revascularization required, potentially leading to a more conservative approach in selected patient populations.

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