Should fractional flow reserve follow angiographic visual inspection to guide preventive percutaneous coronary intervention in ST-elevationmyocardial infarction?

Abstract

We aimed to quantify the effect of preventive percutaneous coronary intervention (PCI to non-infarct arteries) on cardiac death and non-fatal myocardial infarction (MI) in patients with ST-elevation myocardial infarction (STEMI) according to whether the decision to carry out preventive PCI was based on angiographic visual inspection (AVI alone) or AVI plus fractional flow reserve (FFR) if AVI showed significant stenosis (AVI plus FFR). Methods and results Randomized trials comparing preventive PCI with no preventive PCI in STEMI without shock were identified by a systematic literature search and categorized according to whether they used AVI alone or AVI plus FFR to select patients for preventive PCI. Random effects meta-Analyses and tests of heterogeneity were used to compare the two categories in respect of cardiac death and MI as a combined outcome and individually. Eleven eligible trials were identified. For cardiac death and MI, the relative risk estimates for AVI alone vs. AVI plus FFR were 0.39 (0.25 0.61) and 0.85 (0.57 1.28), respectively (P = 0.01 for difference), for cardiac death, alone the estimates were 0.36 (0.19 0.71) and 0.79 (0.36 1.77), respectively (P = 0.15 for difference), and for MI alone, 0.41 (0.23 0.73) and 0.98 (0.62 1.56), respectively (P = 0.04 for difference). Conclusion In preventive PCI among STEMI patients, AVI alone achieves a 60% reduction in cardiac death and MI but selecting patients using FFR in AVI positive patients loses much of the benefit. Angiographic visual inspection is best used without FFR in this group of patients.