ESC 2022: FRAME-AMI sheds light on best strategy for selecting non-infarct lesions for PCI

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Joo-Yong Hahn

Selection of non-infarct related artery (IRA) lesions for intervention using fractional flow reserve (FFR) is superior to routine angiography-based selection in patients with acute myocardial infarction and multivessel disease, researchers have reported.

This was the conclusion of Joo-Yong Hahn (Samsung Medical Center, Seoul, Republic of Korea) presenting findings of the FAME-AMI trial, an investigator-initiated, open-label trial comparing FFR to angiography-guided percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI) with multivessel disease.

Randomised trials have consistently found that PCI of non-IRA lesions for complete revascularisation in patients with ST-segment elevation myocardial infarction (STEMI) improves clinical outcomes compared with IRA-only PCI, Hahn explained. ESC guidelines recommend that revascularisation of non-IRA lesions should be considered in STEMI patients with multivessel disease during the index procedure or before hospital discharge. But, the optimal strategy to select targets for non-IRA PCI has not been clarified.

FRAME-AMI was conducted at 14 sites in Korea, and randomly assigned patients with AMI and multivessel coronary artery disease who had undergone successful PCI of the IRA to undergo either (FFR-guided PCI of non-IRA with FFR ≤0.80 or (angiography-guided PCI of non-IRA with >50% diameter stenosis. In both groups, complete revascularisation during the index procedure was recommended. However, staged procedures during the index hospitalisation were permitted at operators’ discretion. The primary endpoint was a composite of all-cause death, myocardial infarction, or repeat revascularisation.

Between August 2016 and December 2020, a total of 562 patients underwent randomisation. The average age was 63 years and 16% were women. Non-IRA lesions were treated by immediate PCI after successful treatment of IRA in 337 patients (60.0%) and by staged procedure during the same hospitalisation in 225 patients (40.0%). During a median follow up of 3.5 years (interquartile range 2.7–4.1 years), the primary endpoint occurred in 18 of 284 patients in the FFR group and 40 of 278 patients in the angiography group (Kaplan–Meier event rates at 4 years, 7.4% versus 19.7%; hazard ratio [HR] 0.43; 95% confidence interval [CI] 0.25–0.75; p=0.003).

The incidence of death was significantly lower in the FFR group compared with the angiography group, occurring in give patients versus 16 patients, respectively (Kaplan–Meier event rates at 4 years, 2.1% versus 8.5%; HR 0.30; 95% CI 0.11–0.83; p=0.020). The incidence of myocardial infarction was also significantly lower in the FFR group compared with the angiography group, occurring in 7 patients versus 21 patients, respectively (Kaplan–Meier event rates at 4 years, 2.5% versus 8.9%; HR 0.32; 95% CI 0.13–0.75; p=0.009).

Ten patients in the FFR group had an unplanned revascularisation compared with 16 patients in the angiography group, with no significant difference between the two groups (Kaplan–Meier event rates at 4 years, 4.3% versus 9.0%; HR 0.61; 95% CI 0.28–1.34; p=0.216).

Sharing key messages from the study, Hahn commented that the findings shed light on the efficacy and safety of doing selective PCI of non-IRA lesions using FFR-guided decision making in patients with AMI and multivessel disease.

For treatment of non-IRA lesions, FFR-guided PCI reduced the risk of death, MI, or repeat revascularisation with fewer number of stents and less contrast media compared with angiography-guided PCI, Hahn concluded.


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