Fractional flow reserve (FFR) guided revascularization did not demonstrate any benefit over angiography guided revascularization in the FLOWER-MI trial.
In patients with ST-elevated myocardial infarction (STEMI) and multi-vessel disease, complete vascularization is associated with better clinical outcomes than vascularization of only the culprit lesion. Current guidelines recommend the use of FFR to treat culprit lesions in patients with STEMI and multi-vessel disease. It was unclear if FFR could also afford clinical outcomes superior to angiography guidance when used in non-culprit lesions.
Visual assessment of heart valve patency is not a reliable indicator of functionality; therefore, FFR can help guide appropriate decisions regarding percutaneous coronary intervention (PCI) to those vessels that genuinely need it. However, no trial has investigated the use of FFR-guided revascularization in patients with STEMI and multi-vessel disease. The FLOWER-MI study (NCT02943954) randomized 1163 patients who had experienced STEMI and undergone successful PCI and were judged to have at least one additional vessel for which revascularization was recommended, to undergo either angiography-guided PCI (n=577), or FFR-guided PCI (n=586).
The primary outcome was a composite of death from any cause, non-fatal myocardial infarction, or unplanned hospitalization requiring urgent revascularization at 1 year. This outcome was met by 32 (5.5%) participants in the FFR arm and 24 (4.2%) participants in the angiography arm, yielding a hazard ratio of 1.32 (95%CI 0.78-2.23; P=0.31). These results fail to demonstrate a clear benefit of FFR-guided revascularization over angiography-guided revascularization in patients with STEMI and multi-vessel disease at reducing the composite primary outcome of death from any cause, non-fatal MI, or hospitalization requiring urgent revascularization. However, the researchers caution that the wide confidence interval precludes any definitive conclusions.
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Author: Kelly Schoonderwoerd
Original article: Puyrimat E et al. N Engl J Med 2021; 385:297-308