Should Fractional Flow Reserve follow Angiographic Visual Inspection to guide Preventive PCI in STEMI?

Abstract

AIMS: 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 if AVI showed significant stenosis (AVI plus FFR). METHODS AND RESULTS: Randomised trials comparing preventive PCI with no preventive PCI in STEMI without shock were identified by a systematic literature search and categorised 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 versus 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). CONCLUSIONS: In preventive PCI among STEMI patients, AVI alone achieves an approximate 60% reduction in cardiac death and MI but selecting patients using FFR in AVI positive patients loses much of the benefit. AVI is best used without FFR in this group of patients.