Clinical outcomes of complete revascularization using either angiography-guided or fractional flow reserve-guided drug-eluting stent implantation in non-culprit vessels in ST elevation myocardial infarction patients: insights from a study based on a systematic review and meta-analysis

Abstract

Current guidelines recommend that percutaneous coronary intervention (PCI) should be restricted to the culprit vessel in ST elevation myocardial infarction (STEMI) patients with multi-vessel disease (MVD) and without cardiogenic shock. However, newer data suggests that performing complete revascularization (CR) in MVD patients may lead to better outcomes compared to intervention in the culprit vessel only. The aim of this meta-analysis is to examine the available data to determine if CR (using either angio- or fractional flow reserve guidance-FFR) following primary PCI in STEMI patients without cardiogenic shock impacts clinical outcomes. Meta-analysis was performed by conducting a literature search of PubMed from January 2004 to July 2017. Pooled estimates of outcomes, presented as odds ratios (OR) [95% confidence intervals], were generated using random-effect models. A total of 9 studies (3317 patients) were included. CR showed a significant MACE reduction (OR 0.49, 95% CI 0.36-0.66, p < 0.001); All-cause mortality (OR 0.69, 95% CI 0.48-0.98, p = 0.04) and repeat revascularization (OR 0.38, 95% CI 0.28-0.51, p < 0.001) at ≥ 12 months follow-up. The FFR-guiding CR group presented a MACE reduction (odds ratio 0.52, 95% CI 0.30-0.90, p = 0.02) due to a decrease of repeat revascularization (OR 0.41, 95% CI 0.21-0.80, p = 0.009). Overall, performing complete revascularization in STEMI patients showed a MACE reduction, all-cause death and repeat revascularization. Compared to culprit-only revascularization, treating multi-vessel disease in STEMI patients using FFR guidance is associated with decreased incidence of MACE, due to a decreased rate of revascularization.

Quantitative flow ratio for immediate assessment of nonculprit lesions in patients with ST‐segment elevation myocardial infarction—An iSTEMI substudy

“…If further studies support these data, online acute phase QFR could be used for future quick and wire‐independent functional assessment of NCLs, allowing the treating physician to choose between acute and staged complete physiology‐guided revascularization. At this moment, such physiology‐guided assessment requires placement of a pressure wire in the distal segment of the coronary artery, which is time‐ and cost‐consuming and confers a minor risk for the patient . Alternatively, the QFR assessment could be performed offline, for example, by a technician the day after the acute procedure, based on the obtained images.…”

“…Conflicting data exits on whether deferral of nonculprit lesions should be iFR‐ or FFR‐guided in patients with acute coronary syndrome . QFR has been calibrated to mimic FFR despite being an adenosine‐free method.…”

“…V-plot of the classification agreement between acute QFR and staged QFR (A), staged FFR (B), and acute QFR and staged iFR (C) segment of the coronary artery, which is time-and cost-consuming and confers a minor risk for the patient. 10 Alternatively, the QFR assessment could be performed offline, for example, by a technician the day after the acute procedure, based on the obtained images.…”

“…Conflicting data exits on whether deferral of nonculprit lesions should be iFR-or FFR-guided in patients with acute coronary syndrome. 10,15 QFR has been calibrated to mimic FFR despite being an adenosine-free method. It is therefore not surprising that QFR in the acute phase had higher classification agreement with FFR as compared to iFR.…”

Cardiovascular imaging 2018 in the International Journal of Cardiovascular Imaging

“…The aim of this meta-analysis carried out by the team of Hideo-Kajita was to examine the available data to determine if complete revascularization (using either angio-or fractional flow reserve guidance-FFR) following primary PCI in STEMI patients without cardiogenic shock impacts clinical outcomes [10]. A total of nine studies (3317 patients) were included.…”