Reviewer: Dr Derya Baykiz

Name of the Study: FFR Versus Angiography-Guided Strategy for Management of AMI With Multivessel Disease (FRAME-AMI)

Published Congress: ESC 2022

Background:

Randomised trials have found that percutaneous coronary intervention (PCI) of non-infarct related artery (non-IRA) lesions for complete revascularisation in patients with ST-segment elevation myocardial infarction (STEMI) improves clinical outcomes compared with IRA-only PCI. However, the optimal strategy to select targets for non-IRA PCI has not been clarified.

Objective:

The aim of the study is to compare clinical outcomes following fractional flow reserve (FFR)-guided PCI versus angiography-guided PCI for non-IRA stenosis in patients with acute myocardial infarction (MI) with multivessel disease.

Methods:

The present study was an investigator-initiated, open-label trial conducted at 14 sites in Korea. Patients with acute MI with multivessel disease were randomized either FFR-guided PCI of non-IRA with FFR ≤0.80 or angiography-guided PCI of non-IRA with >50% diameter stenosis. In both groups, complete revascularisation during the index procedure was recommended. The primary endpoint was a composite of all-cause death, MI or repeat revascularisation.

Results:

Between 2016 and 2020, a total of 562 patients underwent randomisation (mean age was 63 years, 16% women). During a median follow up of 3.5 years (interquartile range 2.7–4.1 years), the primary endpoint occurred in 18 of 284 patients in the FFR group and 40 of 278 patients in the angiography group (Kaplan–Meier event rates at 4 years, 7.4% versus 19.7%; hazard ratio [HR] 0.43; 95% confidence interval [CI] 0.25–0.75; p=0.003). The incidence of death was significantly lower in the FFR group compared with the angiography group (Kaplan–Meier event rates at 4 years, 2.1% versus 8.5%; HR 0.30? 95% CI 0.11–0.83? p=0.020). The incidence of MI was also significantly lower in the FFR group compared with the angiography group (Kaplan–Meier event rates at 4 years, 2.5% versus 8.9%; HR 0.32? 95% CI 0.13–0.75? p=0.009).

Conclusion:

Using FFR to select non-IRA lesions for PCI was superior to selection based on angiographic diameter stenosis in patients with acute MI and multivessel disease, regarding the risk of death, MI, or repeat revascularisation.

Interpretations:

The benefit of FFR-guided PCI on the primary endpoint was consistent regardless of the type of MI (STEMI or non-STEMI). In clinical practice, interventional cardiologists may choose to adopt FFR-guided decision making in patients with acute MI and multivessel disease.