Clinical Relevance of Fractional Flow Reserve-Guided Percutaneous Coronary Interevention According to Left Ventricular Ejection Fraction in Patients With Acute Myocardial Infarction and Multivessel Disease

Abstract

Background: Fractional flow reserve (FFR)-guided or angiography-guided complete revascularization has not been evaluated in patients with acute myocardial infarction (AMI) with multivessel disease and reduced left ventricular ejection fraction (LVEF). This study sought to evaluate the impact of FFR-guided percutaneous coronary intervention (PCI) for patients with AMI with multivessel disease according to left ventricular systolic function.

Methods: We performed a prespecified analysis of the FRAME-AMI (Fractional Flow Reserve Versus Angiography-Guided Strategy in Acute Myocardial Infarction With Multivessel Disease) trial, which randomly allocated 562 patients to undergo either FFR-guided PCI (FFR ≤0.80) or angiography-guided PCI (diameter stenosis >50%) for non-infarct-related arteries. Patients were classified into preserved (≥50%) and reduced (<50%) LVEF groups. Primary end point was major adverse cardiovascular events, a composite of death, myocardial infarction, and repeat revascularization.

Results: Overall, 187 patients (33.3%) had reduced LVEF. During a median 3.5-year follow-up, patients with AMI with reduced LVEF showed an increased risk of major adverse cardiovascular events compared with those with preserved LVEF (P<0.001). FFR-guided PCI for non-infarct-related arteries significantly reduced major adverse cardiovascular events among patients with preserved LVEF (3.3% versus 19.0%; hazard ratio [HR], 0.26 [95% CI, 0.11-0.66]; P=0.004). Conversely, there was no significant difference in major adverse cardiovascular events between the FFR and angiography-guided PCI among patients with reduced LVEF (17.0% versus 21.0%; HR, 0.64 [95% CI, 0.31-1.31]; P=0.225). In the exploratory analysis, the clinical benefit of FFR-guided PCI was more evident with an increased LVEF (interaction P=0.028).

Conclusions: In patients with AMI with multivessel disease, FFR-guided PCI for a non-infarct-related artery had differential clinical impact according to left ventricular systolic function. The beneficial effect of FFR-guided PCI might be maximized among patients with preserved LVEF rather than reduced LVEF.

Registration: URL: https://clinicaltrials.gov. Unique identifier: NCT02715518.

Keywords: acute myocardial infarction; complete revascularization; fractional flow reserve; left ventricular ejection fraction; percutaneous coronary intervention.