Fractional Flow Reserve-Guided Multivessel Angioplasty in Myocardial Infarction - Compare-Acute

Apr 21, 2020
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Author/Summarized by Author:
Anthony A. Bavry, MD, MPH, FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Trial Sponsor:
Maasstad Cardiovascular Research
Date Presented:
03/18/2017
Date Published:
04/20/2020
Date Updated:
04/21/2020
Original Posted Date:
03/18/2017
References

Contribution To Literature:

The Compare-Acute trial showed that FFR-guided complete revascularization during the index procedure was superior to infarct artery only revascularization.

Description:

The goal of the trial was to evaluate fractional flow reserve (FFR)-guided complete revascularization compared with infarct artery only revascularization among patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI).

Study Design

  • Randomized
  • Parallel
  • Blinded

STEMI patients undergoing primary PCI were randomized to FFR-guided complete revascularization (n = 295) versus infarct artery only revascularization (n = 590). All patients underwent FFR of nonculprit stenoses ≥50%.

In the complete revascularization group, operators were made aware of the FFR value, while in the infarct artery only revascularization group, they were blinded to this value. Complete revascularization was generally performed during the index procedure or within 72 hours if there were clinical reasons to delay the procedure.

  • Total number of enrollees: 885
  • Duration of follow-up: 12 months
  • Mean patient age: 62 years
  • Percentage female: 21%
  • Percentage with diabetes: 15%

Inclusion criteria:

  • Patients 18-85 years of age who presented within 12 hours of symptom onset for STEMI
  • Nonculprit vessel at least 2 mm with ≥50% stenosis

Exclusion criteria:

  • Left main stenosis
  • Chronic total occlusion
  • Severe stenosis
  • TIMI flow <3 in the nonculprit vessel
  • Suboptimal result or complication of treatment of the infarct artery
  • Severe valve disease
  • Killip class III or IV

Other salient features/characteristics:

  • Mean time for index procedure: 65 minutes for complete vs. 59 minutes for infarct artery only (p = 0.001)
  • Mean volume contrast for index procedure: 224 cc for complete vs. 202 cc for infarct artery only (p = 0.007)
  • FFR successful: 99% for complete vs. 98% for infarct artery only (p = 0.13)
  • Approximately half of FFR values were ≤0.8 and half were >0.8

Principal Findings:

The primary outcome, incidence of all-cause death, MI, cerebrovascular event, or any revascularization at 12 months, occurred in 7.8% of the complete group versus 20.5% of the infarct artery only group (p < 0.001).

Secondary outcomes:

  • All-cause death: 1.4% for complete vs. 1.7% for infarct artery only (p = 0.70)
  • MI: 2.4% for complete vs. 4.7% for infarct artery only (p = 0.10)
  • Revascularization: 6.1% for complete vs. 17.5% for infarct artery only (p < 0.001)

Total non-revascularized lesions (176 in the complete revascularization group who had nonischemic FFR measured in nonculprit vessels, 575 in the infarct artery only who had FFR measured in nonculprit vessels):

  • The median FFR was 0.79 among those who required revascularization compared with 0.85 among those who did not require revascularization (p < 0.001).
  • The median FFR was 0.79 among those who had an MI compared with 0.84 among those who did not have an MI (p = 0.016).

Interpretation:

Among STEMI patients undergoing primary PCI, FFR-guided complete revascularization was superior to infarct artery only revascularization. In most cases, FFR-guided complete revascularization occurred during the index procedure and was associated with a reduction in adverse cardiovascular events. There was no difference in mortality or MI. Benefit for complete revascularization was driven by a lower rate of future revascularization procedures. Adverse events among non-revascularized lesions tended to occur with FFR values <0.8.

Numerous randomized trials have now compared complete versus culprit revascularization strategies. The weight of these data support that complete revascularization (guided by angiography or FFR) reduces adverse cardiovascular events, driven by a reduction in future revascularization procedures. Complete revascularization can be performed during the index procedure, during the index hospitalization, or early after discharge. Complete revascularization during the index procedure, which was mostly conducted in this trial, is the most efficient strategy and eliminates the need for future catheterization procedures.

References:

Piróth Z, Boxma-de Klerk BM, Omerovic E, et al. The Natural History of Nonculprit Lesions in STEMI: An FFR Substudy of the Compare-Acute Trial. JACC Cardiovasc Interv 2020;13:954-61.

Smits PC, Abdel-Wahab M, Neumann FJ, et al., on behalf of the Compare-Acute Investigators. Fractional Flow Reserve–Guided Multivessel Angioplasty in Myocardial Infarction. N Engl J Med 2017;376:1234-44.

Presented by Dr. Pieter Smits at the American College of Cardiology Annual Scientific Session (ACC 2017), Washington, DC, March 18, 2017.

Keywords: ACC17, ACC Annual Scientific Session, Acute Coronary Syndrome, Adenosine, Angiography, Fractional Flow Reserve, Myocardial, Hemodynamics, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Vascular Diseases


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