Primary angioplasty and multivessel lesions: how should we proceed?

Courtesy of Dr Carlos Fava.

The association of primary angioplasty with multivessel lesions is not infrequent and has been analyzed in various studies and meta-analyses. However, the proper course of action remains unclear. According to this study, fractional flow reserve (FFR) could better define the ischemic impact of lesions and help with the identification of the correct measures to be taken.

The objective of this post hoc study was to assess the impact of number of diseased vessels, lesion location, and severity of the noninfarct-related stenosis through FFR.

The primary endpoint was a composite of all-cause mortality, reinfarction, and ischemia-driven revascularization.

The study analyzed 627 patients: 430 presented 2-vessel disease (213 patients underwent culprit-vessel primary angioplasty, and the remaining 217 patients underwent complete FFR-guided complete revascularization), while 197 patients had 3-vessel disease (100 of them underwent myocardial-infaction-culprit-artery revascularization, and 97 underwent complete FFR-guided complete revascularization).

There were no significant differences among groups, except for more ≥90% lesions and proximal lesions in the 3-vessel-disease group.

During the 23-month follow-up, patients with 3-vessel disease and FFR-guided complete revascularization presented a reduction in the primary endpoint (hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.17-0.64; p = 0.001). Such a benefit was driven by a lower rate of ischemia-driven revascularization. There was no significant difference regarding patients with 2-vessel disease.

Revascularization of a ≥90% vessel obstruction resulted in more benefit when compared to lower percentage obstructions. Such a benefit was higher when associated with 3-vessel disease and ≥90% obstructions. However, the numeric difference in this group was not significant as regards the reduction in the rates of all-cause death and reinfarction. Location of the noninfarct-related stenosis (proximal versus distal) did not affect the benefit derived from complete revascularization.

Conclusion

The benefit from FFR-guided complete revascularization on ST-segment elevation myocardial infarction in patients with multivessel disease depended on the presence of 3-vessel disease and noninfarct-related artery lesion with diameter stenosis ≥90%, and it was particularly higher for patients presenting both conditions.

Editorial Comment

This sub-study sheds further light on the issue of treating patients with acute myocardial infarction and multivessel lesions. It requires the use of both angiography and other technologies, such as FFR. However, this presents two problems: its unavailability in many sites, and its higher costs.

Further research is warranted in order to produce more solid data on which decisions can be based.

Courtesy of Dr. Carlos Fava

Título original: Fractional Flow Reserve-Guided Complete Revascularization Improves the Prognosis in Patients With ST-Segment-Elevation Myocardial Infarction and Severe Nonculprit disease: A DANAMI 3-PRIMULTY Substudy (Primary PCI in Patients With ST-Elevation Myocardial Infarction and Multivessel Disease: Treatment of Culprit Lesion Only or Complete Revascularization).

Referencia: Jacob Lonborg, et al. Circulation Cardiovascular Intervention 2017;10:e004460.

We are interested in your opinion. Please, leave your comments, thoughts, questions, etc., below. They will be most welcome.