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Fractional Flow Reserve in Acute Myocardial Infarction: A Guide for Non-Culprit Lesions?

Sulimov DS, Abdel-Wahab M, Richardt G - Cardiol Ther (2015)

Bottom Line: In patients presenting with ST-segment elevation myocardial infarction (STEMI) and multi-vessel disease (MVD), the optimal therapy for non-culprit lesions is still a matter of debate.Such an approach, however, may result in overtreatment, because angiography does not provide robust information about the functional severity of MVD.Fractional flow reserve (FFR) measurements can be a valuable guide for non-culprit lesions in acute myocardial infarction, but so far, only the reliability and safety of FFR measurements have been established in this setting.

View Article: PubMed Central - PubMed

Affiliation: Heart Center, Segeberger Kliniken GmbH, Academic Teaching Hospital of the Universities of Kiel, Lübeck, and Hamburg, Bad Segeberg, Germany.

ABSTRACT
In patients presenting with ST-segment elevation myocardial infarction (STEMI) and multi-vessel disease (MVD), the optimal therapy for non-culprit lesions is still a matter of debate. While guidelines discourage a concomitant treatment of infarct- and non-infarct-related arteries, recent studies document advantages of a complete (preventive) revascularization during primary percutaneous coronary intervention. Such an approach, however, may result in overtreatment, because angiography does not provide robust information about the functional severity of MVD. Fractional flow reserve (FFR) measurements can be a valuable guide for non-culprit lesions in acute myocardial infarction, but so far, only the reliability and safety of FFR measurements have been established in this setting. The clinical implications of an FFR-guided treatment strategy in STEMI patients with MVD are currently being tested in a large randomized trial.

No MeSH data available.


Related in: MedlinePlus

A 59 year old patient with acute anterior ST-segment elevation myocardial infarction and multivessel coronary artery disease. a Electrocardiogramat admission with anterior ST elevation. b Culprit lesion in the left anterior descending. c An angiographically at least intermediate lesion of the right coronary artery (RCA). d Fractional flow reserve of the RCA was 0.83, and the decision about the non-culprit vessel based on functional assessment was possible during the primary intervention. However, the rationale of this strategy is being tested in a current trial
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Fig1: A 59 year old patient with acute anterior ST-segment elevation myocardial infarction and multivessel coronary artery disease. a Electrocardiogramat admission with anterior ST elevation. b Culprit lesion in the left anterior descending. c An angiographically at least intermediate lesion of the right coronary artery (RCA). d Fractional flow reserve of the RCA was 0.83, and the decision about the non-culprit vessel based on functional assessment was possible during the primary intervention. However, the rationale of this strategy is being tested in a current trial

Mentions: Although current data have confirmed the reliability and safety of FFR measurements in the setting of MI, the relevance of the obtained information about functional severity of coronary lesions is currently being assessed. The COMPARE ACUTE (ClinicalTrials.gov #NCT01399736) trial is an ongoing prospective, randomized trial carried out at multiple sites across Europe and Asia [35]. Patients are randomly allocated to receive either an FFR-guided multi-vessel PCI vs. culprit-only PCI in the setting of STEMI. The primary study endpoint is a composite of death, MI, any revascularization, or cerebral accident at 12 months. FFR measurements are performed directly after completion of primary PCI in all non-infarct-related arteries with a stenosis of ≥ 50 %. Figure 1 demonstrates a case from the COMPARE ACUTE cohort with an anterior STEMI and multivessel disease. Positive FFR measurements are defined as ≤ 0.80 under maximal hyperemia. Preliminary FFR data of 613 patients show that 56.5 % of the FFR measurements were negative and only 43.5 % were positive [35]. It is worth to mention here that the rate of positive FFR measurements in the FFR-guided group of the FAME trial was 63 %, which underscores the contention that lesions are overestimated by conventional methods in acute patients.Fig. 1


Fractional Flow Reserve in Acute Myocardial Infarction: A Guide for Non-Culprit Lesions?

Sulimov DS, Abdel-Wahab M, Richardt G - Cardiol Ther (2015)

A 59 year old patient with acute anterior ST-segment elevation myocardial infarction and multivessel coronary artery disease. a Electrocardiogramat admission with anterior ST elevation. b Culprit lesion in the left anterior descending. c An angiographically at least intermediate lesion of the right coronary artery (RCA). d Fractional flow reserve of the RCA was 0.83, and the decision about the non-culprit vessel based on functional assessment was possible during the primary intervention. However, the rationale of this strategy is being tested in a current trial
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4472643&req=5

Fig1: A 59 year old patient with acute anterior ST-segment elevation myocardial infarction and multivessel coronary artery disease. a Electrocardiogramat admission with anterior ST elevation. b Culprit lesion in the left anterior descending. c An angiographically at least intermediate lesion of the right coronary artery (RCA). d Fractional flow reserve of the RCA was 0.83, and the decision about the non-culprit vessel based on functional assessment was possible during the primary intervention. However, the rationale of this strategy is being tested in a current trial
Mentions: Although current data have confirmed the reliability and safety of FFR measurements in the setting of MI, the relevance of the obtained information about functional severity of coronary lesions is currently being assessed. The COMPARE ACUTE (ClinicalTrials.gov #NCT01399736) trial is an ongoing prospective, randomized trial carried out at multiple sites across Europe and Asia [35]. Patients are randomly allocated to receive either an FFR-guided multi-vessel PCI vs. culprit-only PCI in the setting of STEMI. The primary study endpoint is a composite of death, MI, any revascularization, or cerebral accident at 12 months. FFR measurements are performed directly after completion of primary PCI in all non-infarct-related arteries with a stenosis of ≥ 50 %. Figure 1 demonstrates a case from the COMPARE ACUTE cohort with an anterior STEMI and multivessel disease. Positive FFR measurements are defined as ≤ 0.80 under maximal hyperemia. Preliminary FFR data of 613 patients show that 56.5 % of the FFR measurements were negative and only 43.5 % were positive [35]. It is worth to mention here that the rate of positive FFR measurements in the FFR-guided group of the FAME trial was 63 %, which underscores the contention that lesions are overestimated by conventional methods in acute patients.Fig. 1

Bottom Line: In patients presenting with ST-segment elevation myocardial infarction (STEMI) and multi-vessel disease (MVD), the optimal therapy for non-culprit lesions is still a matter of debate.Such an approach, however, may result in overtreatment, because angiography does not provide robust information about the functional severity of MVD.Fractional flow reserve (FFR) measurements can be a valuable guide for non-culprit lesions in acute myocardial infarction, but so far, only the reliability and safety of FFR measurements have been established in this setting.

View Article: PubMed Central - PubMed

Affiliation: Heart Center, Segeberger Kliniken GmbH, Academic Teaching Hospital of the Universities of Kiel, Lübeck, and Hamburg, Bad Segeberg, Germany.

ABSTRACT
In patients presenting with ST-segment elevation myocardial infarction (STEMI) and multi-vessel disease (MVD), the optimal therapy for non-culprit lesions is still a matter of debate. While guidelines discourage a concomitant treatment of infarct- and non-infarct-related arteries, recent studies document advantages of a complete (preventive) revascularization during primary percutaneous coronary intervention. Such an approach, however, may result in overtreatment, because angiography does not provide robust information about the functional severity of MVD. Fractional flow reserve (FFR) measurements can be a valuable guide for non-culprit lesions in acute myocardial infarction, but so far, only the reliability and safety of FFR measurements have been established in this setting. The clinical implications of an FFR-guided treatment strategy in STEMI patients with MVD are currently being tested in a large randomized trial.

No MeSH data available.


Related in: MedlinePlus