A-65 | Complete Revascularization in Patients with STEMI and Multivessel Disease: Physiology Guided or Angiography Guided?

Fractional flow reserve (FFR) guided revascularization strategy seems superior to angiography guidance in patients with stable coronary heart disease (SCHD) and non-ST segment elevation acute coronary syndrome (ACS) bearing angiographically significant non-IRA disease, however the role of physiology guidance (FFR, iFR or stress testing) in complete revascularization (CR) of non-IRA lesions in ST-elevation myocardial infarction (STEMI) remains unclear. We searched for randomized controlled trials enrolling subjects with acute STEMI and multi-vessel disease (MVD) with ≥50% stenosis in ≥1 non-IRA amenable to percutaneous coronary intervention (PCI) evaluating physiology guided (FFR, instantaneous wave-free ratio or stress echocardiography) vs. angiography guided index or staged CR. The primary outcome of this study was MACE which was composite of death, MI, and revascularization. The secondary outcomes were CV mortality, non-fatal MI, subsequent coronary revascularization, and all-cause mortality. The outcomes were reported as relative risk (RR) with a 95% confidence interval (CI) using fixed-effect model and p-value of ≤0.05 representing statistically significant effect. Overall, three RCTs were included comprising of 1,734 (∼50% in each arm) patients with a mean follow-up duration ∼28 months. In analysis of 1,734 patients with STEMI and MVD, there was no significant difference in MACE between physiology guided vs. angiography guided CR (7.1% vs. 6.8%, RR 1.05, 0.74-1.48, p=0.79) (Figure.1). Similarly, there was no statistically significant difference between the two revascularization strategies regarding CV mortality (0.9% vs. 0.8%, RR, 1.17, 0.38-3.57, p=0.78), MI (3.4% vs. 3.4%, RR: 1.00, 0.56-1.77, p=0.99), coronary revascularization (7.6% vs. 5.7%, RR: 1.32, 0.90-1.94, p=0.16) and all-cause mortality (1.4% vs. 1.8%, RR: 0.78, 0.34-1.78, p=0.55) (Figure.1). Based on sensitivity analysis, no difference of results was observed with excluding one trial each. Both physiology guided and angiography guided CR strategies result in similar MACE in patients with STEMI having MVD without cardiogenic shock. These findings should be validated in future trials.