Flow Evaluation to Guide Revascularization in Multivessel ST-Elevation Myocardial Infarction - FLOWER-MI

Contribution To Literature:

Highlighted text has been updated as of August 27, 2023.

The FLOWER-MI trial failed to show that FFR-guided complete revascularization was superior to angiography-guided complete revascularization.


The goal of the trial was to evaluate complete revascularization guided by fractional flow reserve (FFR) versus angiography among patients with ST-segment elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention (PCI) of their culprit vessel.

Study Design

  • Randomized
  • Parallel
  • Stratified

Patients who underwent primary PCI for STEMI and had nonculprit multivessel coronary disease were randomized to FFR-guided revascularization (n = 590) versus angiography-guided revascularization (n = 581).

  • Total number of enrollees: 1,171
  • Duration of follow-up: 36 months
  • Mean patient age: 63 years
  • Percentage female: 15%
  • Percentage with diabetes: 18%

Inclusion criteria:

  • Patients ≥18 years of age with STEMI and multivessel nonculprit coronary disease
  • Successful culprit lesion PCI

Exclusion criteria:

  • Single-vessel coronary disease
  • Hemodynamic instability
  • Previous coronary artery bypass grafting
  • Extreme coronary artery calcification or tortuosity
  • Chronic total occlusion
  • Pregnancy

Other salient features/characteristics:

  • Nonculprit PCI was generally performed in a staged fashion (97%)
  • Nonculprit PCI per patient: 66% in the FFR-guided group versus 97% in the angiography-guided group
  • Mean number of stents per patient for nonculprit lesions: 1.01 in the FFR-guided group versus 1.50 in the angiography-guided group

Principal Findings:

The primary outcome of death, MI, or urgent revascularization at 12 months occurred in 5.5% of the FFR-guided group compared with 4.2% of the angiography-guided group (p = 0.31).

Secondary outcomes:

  • Nonfatal MI at 12 months: 3.1% of the FFR-guided group compared with 1.7% of the angiography-guided group (p = nonsignificant)
  • Urgent revascularization at 12 months: 2.6% of the FFR-guided group compared with 1.9% of the angiography-guided group (p = nonsignificant)

3-year outcomes:

  • Death, MI, or urgent revascularization at 3 years: 8.9% of the FFR-guided group compared with 7.6% of the angiography-guided group (p = 0.41)


Among patients who underwent primary PCI for STEMI and had nonculprit multivessel coronary disease, FFR-guided revascularization was not superior to angiography-guided revascularization. An FFR-guided strategy failed to reduce the composite outcome of death, MI, or urgent revascularization, compared with an angiography-guided strategy out to 3 years. Current guidelines recommend that complete revascularization be considered during the index hospitalization for STEMI patients with multivessel coronary disease. Based on this trial, either an FFR-guided or an angiography-guided strategy are acceptable choices for the management of residual coronary artery disease after primary PCI.


Presented by Dr. Nicolas Danchin at the European Society of Cardiology Congress, Amsterdam, Netherlands, August 27, 2023.

Puymirat E, Cayla G, Simon T, et al., on behalf of the FLOWER-MI Study Investigators. Multivessel PCI Guided by FFR or Angiography for Myocardial Infarction. N Engl J Med 2021;385:297-308.

Presented by Dr. Etienne Puymirat at the American College of Cardiology Virtual Annual Scientific Session (ACC 2021), May 16, 2021.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and SIHD, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Chronic Angina

Keywords: ACC21, ACC Annual Scientific Session, Acute Coronary Syndrome, Angiography, Anterior Wall Myocardial Infarction, Coronary Artery Disease, ESC Congress, ESC23, Fractional Flow Reserve, Myocardial, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, ST Elevation Myocardial Infarction, Stents

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