Differential outcomes in FFR-guided versus angiography-guided revascularization strategy according to target non-infarct related vessels: from FRAME-AMI trial

Abstract

Abstract Background Incomplete revascularization of non-infarct related arteries (IRA) leads to worse outcomes in patients with acute myocardial infarction (AMI) and multivessel coronary artery disease (MVD). Outcomes of fractional flow reserve (FFR)- and angiography-guided percutaneous coronary intervention (PCI) for non-IRA may differ according to their location between the anterior descending artery (LAD) and non-LAD. Aims We investigated the impact of FFR- versus angiography-guided PCI on clinical outcomes according to the location of non-IRA (LAD versus non-LAD) in AMI patients with MVD. Methods This trial was a pre-specified post-hoc analysis of the FRAME-AMI study, an investigator-initiated, randomized, open-label, multicenter trial at 14 sites in Korea. In the FRAME-AMI trial, PCI was performed for non-IRA in 64.1% (FFR £0.80) and 97.1% (diameter stenosis of >50%) in FFR-guided PCI and angiography-guided PCI groups, respectively. We grouped the patients into four according to treatment strategy (FFR versus angiography) and location of non-IRA (LAD vs. non-LAD). The primary endpoint was a composite of time to death, MI, or repeat revascularization. Results Patients with non-IRA involving LAD and non-LAD were 55.0% and 45.0%, respectively. The proportion of performed PCI (82.2% vs. 78.3%, p=0.242) and the rate of the primary outcome (9.4% vs. 11.5%, p=0.421) were similar between LAD and non-LAD. Among patients with non-IRA involving LAD, the FFR-guided group had a fewer events rate of the primary outcome than the angiography-guided group (5.7% vs. 14.3%, p=0.010). Among those with non-IRA not involving LAD, the FFR-guided group tended to the lower incidence of the primary outcome compared to the angiography-guided group (7.4% vs. 14.5%, p=0.081). However, the effect of the interaction between LAD and non-LAD on the primary outcome was not found (p for interaction 0.667). Conclusions In AMI patients with MVD, FFR-directed PCI for non-IRA was superior to angiography-guided PCI regardless of the location of non-IRA. The benefit of an FFR-directed revascularization strategy for non-IRA is likely enhanced in LAD.