Response by Puymirat and Danchin to Letter Regarding Article, "Compared Outcomes of ST-Segment-Elevation Myocardial Infarction Patients With Multivessel Disease Treated With Primary Percutaneous Coronary Intervention and Preserved Fractional Flow Reserve of Nonculprit Lesions Treated Conservatively and of Those With Low Fractional Flow Reserve Managed Invasively: Insights From the FLOWER-MI Trial".

Abstract

HomeCirculation: Cardiovascular InterventionsVol. 15, No. 1Response by Puymirat and Danchin to Letter Regarding Article, “Compared Outcomes of ST-Segment–Elevation Myocardial Infarction Patients With Multivessel Disease Treated With Primary Percutaneous Coronary Intervention and Preserved Fractional Flow Reserve of Nonculprit Lesions Treated Conservatively and of Those With Low Fractional Flow Reserve Managed Invasively: Insights From the FLOWER-MI Trial” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessLetterPDF/EPUBResponse by Puymirat and Danchin to Letter Regarding Article, “Compared Outcomes of ST-Segment–Elevation Myocardial Infarction Patients With Multivessel Disease Treated With Primary Percutaneous Coronary Intervention and Preserved Fractional Flow Reserve of Nonculprit Lesions Treated Conservatively and of Those With Low Fractional Flow Reserve Managed Invasively: Insights From the FLOWER-MI Trial” Etienne Puymirat, MD, PhD and Nicolas Danchin, MD Etienne PuymiratEtienne Puymirat https://orcid.org/0000-0002-0533-9682 Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Department of Cardiology, France. Université de Paris, France. Search for more papers by this author and Nicolas DanchinNicolas Danchin https://orcid.org/0000-0001-9263-5051 Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Department of Cardiology, France. Université de Paris, France. Search for more papers by this author Originally published18 Jan 2022https://doi.org/10.1161/CIRCINTERVENTIONS.121.011667Circulation: Cardiovascular Interventions. 2022;15:e011667In Response:Cerrato and Escaned report that the conclusions of their patient-level meta-analysis of cohorts of patients with either stable angina pectoris or acute coronary syndrome in whom percutaneous coronary intervention was deferred on the basis of fractional flow reserve measurements are in line with our findings from the FLOWER-MI trial (FLOW Evaluation to Guide Revascularization in Multi-Vessel ST-Elevation Myocardial Infarction).1–3 In fact, in patients with deferred percutaneous coronary intervention, they observed a higher major adverse cardiac events (MACE) rate after acute coronary syndrome, compared with MACE occurring in stable patients (hazard ratio, 1.72 [95% CI, 1.17–2.53]); however, in contrast with what we observed, MACE rates were lower in patients with acute coronary syndrome with deferred percutaneous coronary intervention (52/1166, 4.46%) versus those in whom percutaneous coronary intervention was actually performed (62/952, 6.51%; Table). We, therefore, do not understand why the authors now conclude from their analysis that deferring revascularization in nonculprit lesions with fractional flow reserve >0.80 was associated with an increased risk of events. The reasons for the discrepancy between our results and those of Cerrato et al are speculative.Table. MACE in ACS Patients With FFR-Guided Management According to Deferring or Performing PCI in the FLOWER-MI Cohort2 and in the Cerrato et al Meta-Analysis1FLOWER-MIMeta-analysisDeferred (n=198)Treated (n=388)Deferred (n=1166)Treated (n=952)MACE, n (%)16 (8.1)16 (4.1)52 (4.5)62 (6.5)ACS indicates acute coronary syndrome; FFR, fractional flow reserve; FLOWER-MI, FLOW Evaluation to Guide Revascularization in Multi-Vessel ST-Elevation Myocardial Infarction; MACE, major adverse cardiac events; and PCI, percutaneous coronary intervention.As regards the timing of MACE, although there were no MACE in the first 30 days in our population, the slope of events after one month was quite even, just as was the case for the slope of MACE after 2 weeks in the Cerrato meta-analysis. As MACE remained rare in both FLOWER-MI and the meta-analysis, one must be cautious of not over-interpreting possible differences in the timing of events. We recognize, however, that there may have been differences in the mechanisms leading to MACE in the FLOWER-MI population, which comprised only patients with ST-segment–elevation myocardial infarction, and in the meta-analysis population, that comprised both patients with ST-segment–elevation myocardial infarction and non–ST-segment–elevation myocardial infarction.Article InformationDisclosuresNone.