Using fractional flow reserve (FFR) to guide revascularization of all functionally significant lesions in the setting of acute coronary syndrome appears to improve outcomes over treating only the culprit artery, according to the Compare-Acute trial.
This study, conducted at 24 centers in Europe and Asia, enrolled 885 patients who were stable following successful primary angioplasty and randomized them 1:2 to treatment of all functionally significant lesions (preferably during the index procedure) or of the culprit artery only. FFR was performed in both groups, but results were blinded to patients and operators in the control group.
The primary endpoint (Major Adverse Cardiovascular and Cerebrovascular Event, MACCE) occurred in 7.8% of patients who underwent FFR-guided complete revascularization, and in 20.5% of those who received angioplasty of the culprit artery alone at 1 year (hazard ratio [HR]: 0.35; 95% confidence interval [CI]: 0.22-0.55).
The advantage was driven by a reduction in repeat revascularization (6.1% vs. 17.5%; HR: 0.32; 95% CI: 0.20-0.54), with no differences in the other components of the composite primary endpoint, including all-cause death, nonfatal infarction, or cerebrovascular events.
About half of the non-infarct-related culprit lesions were identified as significant on angiography, although their FFR values were above 0.8.
In a subgroup analysis, patients who underwent treatment of the culprit artery, with non-significant FFR values in other lesions, had results very similar to those who underwent additional interventions because of positive FFR values.
Thus, deferring treatment of lesions with negative FFR values in these patients could be considered safe and efficient.
However, additional costs due to FFR measurement should be taken into account, since only about 20% of patients in the culprit vessel-only arm of the trial required additional revascularization. Some consider that this approach is not cost-effective, since the FFR strategy did not reduce any “hard” endpoint, such as death or infarction.
Definitive information will probably come from studies such as COMPLETE and FULL-REVASC, each with enrollments of 4000 patients, and statistical power strong enough to show differences in hard clinical outcomes.
Original titles: Fractional flow reserve-guided multivessel angioplasty in myocardial infarction and Complete revascularization in ST-elevation myocardial infarction?
Reference: Both studies were presented at the 2017 ACC Scientific Session and published simultaneously by the N Engl J Med.
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