Evaluation and Management of Nonculprit Lesions in STEMI

Thim, Troels; Hoeven, Nina W. van der; Musto, Carmine; Nijveldt, Robin; Götberg, Matthias; Engstrøm, Thomas; Smits, Pieter C.; Oldroyd, Keith G.; Gershlick, Anthony; Escaned, Javier; Baptista, Sérgio Bravo; Raposo, Luís; Royen, Niels van; Mæng, Michael

doi:10.1016/j.jcin.2020.02.030

Cited by 44 publications

(43 citation statements)

References 33 publications

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“…Within < 5 days after STEMI, both iFR and FFR may be affected, but in opposite directions, and the optimal method for nonculprit stenosis evaluation in this setting remains undetermined [4][5][6][7][8]. Also, the optimal time point for making this assessment remains to be established [2]. Different methods can be applied taking timing and potential bias of the used method in relation to timing into consideration [2].…”

Section: Discussionmentioning

confidence: 99%

“…Also, the optimal time point for making this assessment remains to be established [ 2 ]. Different methods can be applied taking timing and potential bias of the used method in relation to timing into consideration [ 2 ]. In the acute or subacute setting, baseline flow may be increased and hyperemic flow may be decreased which may yield decreased iFR (overestimation of stenosis significance) and increased FFR (underestimation of stenosis significance) and these changes are expected to normalize over time although the time frame for this normalization is undetermined and may vary between patients [ 4 – 6 ].…”

Section: Discussionmentioning

confidence: 99%

“…In patients with ST-segment elevation myocardial infarction (STEMI), nonculprit coronary stenoses may be identified [1]. Staged evaluation of these stenoses may rely on angiography alone, instantaneous wave free ratio (iFR), fractional flow reserve (FFR) or other invasive or noninvasive methods [2].…”

Section: Introductionmentioning

confidence: 99%

“…In stable patients, the agreement between iFR and FFR in determining hemodynamic significance is approximately 80% [3]. In patients with recent myocardial infarction, baseline coronary blood flow may be increased while maximal hyperaemic blood flow may be decreased in both culprit and nonculprit arteries [2,4]. Increased baseline flow will tend to lower iFR values leading to overestimation of the hemodynamic significance of stenoses, while decreased maximal hyperaemic blood flow will tend to increase FFR values leading to underestimation of the hemodynamic significance of stenosis [2,4].…”

Section: Introductionmentioning

confidence: 99%

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Agreement between nonculprit stenosis follow-up iFR and FFR after STEMI (iSTEMI substudy)

et al. 2020

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Objective: To evaluate agreement between instantaneous wave free ratio (iFR) and fractional flow reserve (FFR) for the functional assessment of nonculprit coronary stenoses at staged follow-up after ST-segment elevation myocardial infarction (STEMI). Results: We measured iFR and FFR at staged follow-up in 112 STEMI patients with 146 nonculprit stenoses. Median interval between STEMI and follow-up was 16 (interquartile range 5-32) days. Agreement between iFR and FFR was 77% < 5 days after STEMI and 86% after ≥ 5 days (p = 0.19). Among cases with disagreement, the proportion of cases with hemodynamically significant iFR and non-significant FFR were different when assessed < 5 days (5 in 8, 63%) versus ≥ 5 days (3 in 15, 20%) after STEMI (p = 0.04). Overall classification agreement between iFR and FFR was comparable to that observed in stable patients. Time interval between STEMI and follow-up evaluation may impact agreement between iFR and FFR.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Agreement between nonculprit stenosis follow-up iFR and FFR after STEMI (iSTEMI substudy)

et al. 2020

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“…The selection of nonculprit lesions qualifying for revascularisation is often based on whether a lesion causes ischaemia, as determined by invasive measurements such as the fractional flow reserve (FFR). 7 In patients with stable coronary artery disease (CAD), FFR-guided complete revascularisation results in better outcomes compared with angiography-guided complete revascularisation. 8 Nevertheless, the MACE rates at longer term follow-up remain significant in the presence of nonsignificant CAD.…”

Section: Introductionmentioning

confidence: 99%

Identification of anatomic risk factors for acute coronary events by optical coherence tomography in patients with myocardial infarction and residual nonflow limiting lesions: rationale and design of the PECTUS-obs study

et al. 2021

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IntroductionIn patients with myocardial infarction, the decision to treat a nonculprit lesion is generally based on its physiological significance. However, deferral of revascularisation based on nonischaemic fractional flow reserve (FFR) values in these patients results in less favourable outcomes compared with patients with stable coronary artery disease, potentially caused by vulnerable nonculprit lesions. Intravascular optical coherence tomography (OCT) imaging allows for in vivo morphological assessment of plaque ‘vulnerability’ and might aid in the detection of FFR-negative lesions at high risk for recurrent events.Methods and analysisThe PECTUS-obs study is an international multicentre prospective observational study that aims to relate OCT-derived vulnerable plaque characteristics of nonflow limiting, nonculprit lesions to clinical outcome in patients with myocardial infarction. A total of 438 patients presenting with myocardial infarction (ST-elevation myocardial infarction and non-ST-elevation myocardial infarction) will undergo OCT-imaging of any FFR-negative nonculprit lesion for detection of plaque vulnerability. The primary study endpoint is a composite of major adverse cardiovascular events (all-cause mortality, nonfatal myocardial infarction or unplanned revascularisation) at 2-year follow-up. Secondary endpoints will be the same composite at 1-year and 5-year follow-up, target vessel failure, target vessel revascularisation, target lesion failure and target lesion revascularisation.Ethics and disseminationThis study has been approved by the Medical Ethics Committee of the region Arnhem-Nijmegen. The results of this study will be disseminated in a main paper and additional papers with subgroup analyses.Trial registration numberNCT03857971.

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Cost-Effectiveness of Fractional Flow Reserve–Guided Treatment for Acute Myocardial Infarction and Multivessel Disease

Hong,

Lee,

Lee

et al. 2024

JAMA Netw Open

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ImportanceComplete revascularization by non–infarct-related artery (IRA) percutaneous coronary intervention (PCI) in patients with acute myocardial infarction is standard practice to improve patient prognosis. However, it is unclear whether a fractional flow reserve (FFR)–guided or angiography-guided treatment strategy for non-IRA PCI would be more cost-effective.ObjectiveTo evaluate the cost-effectiveness of FFR-guided compared with angiography-guided PCI in patients with acute myocardial infarction and multivessel disease.Design, Setting, and ParticipantsIn this prespecified cost-effectiveness analysis of the FRAME-AMI randomized clinical trial, patients were randomly allocated to either FFR-guided or angiography-guided PCI for non-IRA lesions between August 19, 2016, and December 24, 2020. Patients were aged 19 years or older, had ST-segment elevation myocardial infarction (STEMI) or non-STEMI and underwent successful primary or urgent PCI, and had at least 1 non-IRA lesion (diameter stenosis &gt;50% in a major epicardial coronary artery or major side branch with a vessel diameter of ≥2.0 mm). Data analysis was performed on August 27, 2023.InterventionFractional flow reserve–guided vs angiography-guided PCI for non-IRA lesions.Main Outcomes and MeasuresThe model simulated death, myocardial infarction, and repeat revascularization. Future medical costs and benefits were discounted by 4.5% per year. The main outcomes were quality-adjusted life-years (QALYs), direct medical costs, incremental cost-effectiveness ratio (ICER), and incremental net monetary benefit (INB) of FFR-guided PCI compared with angiography-guided PCI. State-transition Markov models were applied to the Korean, US, and European health care systems using medical cost (presented in US dollars), utilities data, and transition probabilities from meta-analysis of previous trials.ResultsThe FRAME-AMI trial randomized 562 patients, with a mean (SD) age of 63.3 (11.4) years. Most patients were men (474 [84.3%]). Fractional flow reserve–guided PCI increased QALYs by 0.06 compared with angiography-guided PCI. The total cumulative cost per patient was estimated as $1208 less for FFR-guided compared with angiography-guided PCI. The ICER was −$19 484 and the INB was $3378, indicating that FFR-guided PCI was more cost-effective for patients with acute myocardial infarction and multivessel disease. Probabilistic sensitivity analysis showed consistent results and the likelihood iteration of cost-effectiveness in FFR-guided PCI was 97%. When transition probabilities from the pairwise meta-analysis of the FLOWER-MI and FRAME-AMI trials were used, FFR-guided PCI was more cost-effective than angiography-guided PCI in the Korean, US, and European health care systems, with an INB of $3910, $8557, and $2210, respectively. In probabilistic sensitivity analysis, the likelihood iteration of cost-effectiveness with FFR-guided PCI was 85%, 82%, and 31% for the Korean, US, and European health care systems, respectively.Conclusions and RelevanceThis cost-effectiveness analysis suggests that FFR-guided PCI for non-IRA lesions saved medical costs and increased quality of life better than angiography-guided PCI for patients with acute myocardial infarction and multivessel disease. Fractional flow reserve–guided PCI should be considered in determining the treatment strategy for non-IRA stenoses in these patients.Trial RegistrationClinicalTrials.gov Identifier: NCT02715518

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Evaluation and Management of Nonculprit Lesions in STEMI

Cited by 44 publications

References 33 publications

Agreement between nonculprit stenosis follow-up iFR and FFR after STEMI (iSTEMI substudy)

Agreement between nonculprit stenosis follow-up iFR and FFR after STEMI (iSTEMI substudy)

Identification of anatomic risk factors for acute coronary events by optical coherence tomography in patients with myocardial infarction and residual nonflow limiting lesions: rationale and design of the PECTUS-obs study

Cost-Effectiveness of Fractional Flow Reserve–Guided Treatment for Acute Myocardial Infarction and Multivessel Disease

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