FFR-Guidance for Complete Nonculprit Revascularization - FULL REVASC

Apr 08, 2024
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Author/Summarized by Author:
Anthony A. Bavry, MD, MPH, FACC
Summary Reviewer:
Kim A. Eagle, MD, MACC
Trial Sponsor:
Swedish Research Council, Swedish Heart–Lung Foundation, and Stockholm County Council
Date Presented:
04/08/2024
Date Published:
04/08/2024
Original Posted Date:
04/08/2024
References

Contribution To Literature:

The FULL REVASC trial failed to show that physiology-guided complete revascularization during STEMI improves outcomes.

Description:

The goal of the trial was to evaluate physiology-guided complete revascularization compared with usual care among patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary disease who underwent culprit-vessel percutaneous coronary intervention (PCI).

Study Design

  • Randomized
  • Parallel
  • Blinded

Patients with STEMI who underwent culprit-vessel PCI were randomized to physiology-guided revascularization of the nonculprit lesions (n = 764) vs. usual care (n = 778). Coronary physiology was assessed by fractional flow reserve (FFR).

  • Total number of enrollees: 1,542
  • Duration of follow-up: median 4.8 years
  • Mean patient age: 65 years
  • Percentage female: 21%
  • Percentage with diabetes: 16%

Inclusion criteria:

  • STEMI and culprit-vessel PCI
  • ≥1 nonculprit lesion

Exclusion criteria:

  • Previous coronary artery bypass grafting
  • Left main disease
  • Cardiogenic shock

Other salient features/characteristics:

  • FFR ≤0.8 in nonculprit lesions: 47%
  • Complete revascularization was achieved in 94% of those with documented ischemia

Principal Findings:

The primary outcome (death, MI, or unplanned revascularization) at a median of 4.8 years occurred in 19.0% of the complete revascularization group vs. 20.4% of the usual care group (p = 0.53).

Secondary outcomes:

  • Death or MI: 16.5% of the complete revascularization group vs. 15.3% of the usual care group (p = not significant [NS])
  • Unplanned revascularization: 9.2% of the complete revascularization group vs. 11.7% of the usual care group (p = NS)

Interpretation:

Among patients with STEMI who underwent culprit-vessel PCI, physiology-guided revascularization of nonculprit lesions failed to improve clinical outcomes. Complete revascularization did not reduce the primary outcome (death, MI, or unplanned) at a median of 4.8 years. Physiology-guided revascularization also failed to reduce death or MI and failed to reduce unplanned revascularization compared with usual care. These findings are different from several previous trials. The COMPLETE trial documented a lower incidence of cardiovascular death or MI with angiography-guided complete revascularization. The FIRE trial documented a lower incidence of cardiovascular death or MI with physiology-guided complete revascularization.

References:

Böhm F, Mogensen B, Engstrøm T, et al., on behalf of the FULL REVASC Trial Investigators. FFR-Guided Complete or Culprit-Only PCI in Patients With Myocardial Infarction. N Engl J Med 2024;390:1481-92.

Editorial: Kunadian V. Role of Physiology in the Management of Nonculprit Lesions in Acute Coronary Syndrome. N Engl J Med 2024;390:1527-9.

Presented by Dr. Felix Böhm at the American College of Cardiology Annual Scientific Session (ACC.24), Atlanta, GA, April 8, 2024.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease

Keywords: ACC24, ACC Annual Scientific Session, Coronary Artery Disease, Myocardial Revascularization


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