Fractional Flow Reserve Versus Angiography for Multivessel Evaluation 3 - FAME 3

Contribution To Literature:

The FAME 3 trial demonstrated that FFR-guided PCI using current-generation DES did not meet criteria for noninferiority compared with CABG among patients with angiographic three-vessel disease.

Description:

The goal of the trial was to demonstrate the noninferiority of fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) to coronary artery bypass grafting (CABG) for patients with three-vessel disease. 

Study Design

Eligible patients were randomized in a 1:1 fashion to either FFR-guided PCI (n = 757) or CABG (n = 743). In the PCI arm, all lesions with FFR value ≤0.80 were stented with current-generation drug-eluting stents (DES). All patients were preloaded with P2Y12 inhibitors and high-dose statin. Post-PCI FFR measurement was recommended. DAPT was continued for at least 6 months. In the CABG arm, FFR could be pursued during diagnostic angiography but not mandated; decision to revascularize was based on the angiogram. Left internal mammary artery was required to be used in all cases, and complete arterial revascularization was recommended.

  • Total number of enrollees: 1,500
  • Duration of follow-up: 1 year
  • Mean patient age: 65 years
  • Percentage female: 18%
  • Race: white 93%

Inclusion criteria:

  • Angiographic ≥50% stenosis in three major epicardial vessels without left main involvement
  • Amenable to revascularization by both PCI and CABG

Exclusion criteria:

  • Cardiogenic shock
  • Recent ST-segment elevation myocardial infarction (STEMI) within 5 days
  • Left ventricular ejection fraction (LVEF) <30%

Other salient features/characteristics:

  • Diabetes: 28%
  • Acute coronary syndrome presentation: 40%
  • EF ≤50%: 18%
  • SYNTAX score 26 (low 33%, intermediate 49%)
  • ≤1 chronic total occlusion 22%
  • FFR measured in 82% in PCI arm; PCI deferred in 24% of lesions

Principal Findings:

The primary endpoint, major adverse cardiovascular and cerebrovascular events (MACCE; death, MI, stroke, repeat revascularization) at 1 year for PCI vs. CABG was: 10.6% vs. 6.9% (hazard ratio 1.5, 95% confidence interval 1.1-2.2, p = 0.35 for noninferiority).

  • Death: 1.6% vs. 0.9%
  • MI: 5.2% vs. 3.5% (spontaneous MI: 3.3% vs. 2.3%)
  • Stroke: 0.9% vs. 1.1%
  • Repeat revascularization: 5.9% vs. 3.9%

Stratified by SYNTAX score for PCI vs. CABG:

  • Low SYNTAX (0-22): 5.5% vs. 8.6%, intermediate (23-32): 13.7% vs. 6.1%, high (>32): 12.1% vs. 6.6% (p = 0.02)

Secondary outcomes for PCI vs. CABG:

  • Bleeding Academic Research Consortium (BARC) 3-5 bleeding: 1.6% vs. 3.8% (p < 0.01)
  • Acute kidney injury: 0.1% vs. 0.9% (p < 0.04)
  • Atrial fibrillation/atrial arrhythmia: 2.4% vs. 14.1% (p < 0.001)
  • Definite stent thrombosis vs. symptomatic graft occlusion: 0.8% vs. 1.3%

Interpretation:

The results of this trial indicate that FFR-guided PCI using current-generation DES did not meet criteria for noninferiority compared with CABG among patients with angiographic three-vessel disease. These are important findings. Prior trials comparing PCI to CABG had used bare-metal stents or first-generation DES (SYNTAX) and did not incorporate systematic ischemic evaluation as was done here using FFR.

On subgroup analysis, there did appear to be benefit with PCI among patients with low SYNTAX scores (0-22). This is hypothesis generating and will need to be confirmed in subsequent studies. An important limitation is the relatively short duration of follow-up (1 year) at this time. Intravascular ultrasound/optical coherence tomography was used in only 12% of patients—this may help optimize PCI outcomes further. Patients with type 2 diabetes mellitus and low EF were also included—in these patients, CABG currently has a Class I indication as preferred mode of revascularization.

References:

Fearon WF, Zimmermann FM, De Bruyne B, et al., on behalf of the FAME 3 Investigators. Fractional Flow Reserve–Guided PCI as Compared With Coronary Bypass Surgery. N Engl J Med 2021;Nov 4:[Epub ahead of print].

Presented by Dr. William F. Fearon at the Transcatheter Cardiovascular Therapeutics (TCT) Conference, Orlando, FL, November 4, 2021.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Acute Kidney Injury, Angiography, Atrial Fibrillation, Constriction, Pathologic, Coronary Artery Bypass, Diabetes Mellitus, Type 2, Drug-Eluting Stents, Fractional Flow Reserve, Myocardial, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Stents, Stroke, TCT21, Thrombosis, Transcatheter Cardiovascular Therapeutics, Vascular Diseases


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