In patients who have experienced myocardial infarction (MI), complete revascularization achieves better clinical outcomes than revascularization of only the infarct-related artery. This finding is true for both ST-elevation MI (STEMI) and non-ST-elevation MI (NSTEMI) lesions. Accordingly, guidelines recommend percutaneous coronary intervention (PCI) for both infarct-related and non-infarct-related (non-IRA) arteries in patients with multi-vessel disease (MVD). However, the optimal strategy to select non-IRA lesions for revascularization is unclear. The FRAME-AMI trial (NCT02715518) compared clinical outcomes using fractional flow reserve, FFR-guided PCI, versus an angiography-guided strategy to treat non-IRA lesions.
Researchers enrolled 562 patients with acute MI and MVD undergoing PCI for non-IRA lesions. The trial randomized patients to either an FFR-guided group (n=284) or an angiography-guided PCI group (n=278). Investigators defined the primary outcome as a composite of death, MI, or repeat revascularization.
Fewer PCIs and deaths with FFR-guided PCI
At a median follow-up of 3.5 years, 18 of 284 patients in the FFR-guided group, and 40 of the 278 patients in the angiography-guided PCI group achieved the primary endpoint (hazard ratio, 0.43; 95% confidence interval 0.25–0.75; P=0.003). In the FFR-guided group, 64.1% of patients underwent PCI, as compared with 97.1% of patients in the angiography-guided group. Death occurred in five (2.1%) patients in the FFR-guided group and in 16 patients (8.5%) in the angiography-guided PCI group.
Investigators concluded that in patients with acute MI and MVD, superior clinical outcomes are achieved by using a strategy of FFR-guided decision-making rather than angiography-guided decision-making for the treatment of non-IRA lesions.
FRAME-AMI adds to the growing body of literature exploring FFR-guided PCI. FLOWER-MI showed that in patients with STEMI and MVD, FFR-guided revascularization did not demonstrate any benefit over angiography guided revascularization. The FLAVOUR trial demonstrated that in patients with coronary artery disease and intermediate stenosis, FFR-guided PCI is non-inferior to intravascular ultrasound-guided PCI. In FAME 3, FFR-guided PCI was not noninferior to CABG in patients with three-vessel coronary artery disease.
Author: Kelly Schoonderwoerd
Original article: Lee JM et al. Eur Heart J. 2022;00:1-12.