The advantage in Compare-Acute was mostly due to fewer repeat revascularizations; larger trials are needed to assess hard outcomes.
WASHINGTON, DC—Using fractional flow reserve (FFR) to guide revascularization of all functionally significant lesions in the setting of acute STEMI appears to improve outcomes over treating only the culprit artery, the Compare-Acute trial shows.
The primary MACCE endpoint occurred in 7.8% of patients who underwent FFR-guided complete revascularization and 20.5% of those who received PCI of the infarct-related artery alone through 1 year (HR 0.35; 95% CI 0.22-0.55), Pieter Smits, MD, PhD (Maasstad Hospital, Rotterdam, the Netherlands), reported at the American College of Cardiology 2017 Scientific Session here.
The advantage was driven primarily by a reduction in repeat revascularization (6.1% vs 17.5%; HR 0.32; 95% CI 0.20-0.54), with no differences in the other components of the composite endpoint, including all-cause death, nonfatal MI, and cerebrovascular events.
Smits noted that about half of the lesions in non-infarct-related arteries that were identified as significant on angiography had FFR values above 0.8, indicating that they were not flow-limiting. A subgroup analysis confined to the complete revascularization arm of the trial showed that patients who did not have non-infarct-related arteries treated because of negative FFR findings had event rates similar to those who underwent additional interventions because of positive FFR values.
Thus, Smits concluded, “deferring treatment of angiographically significant coronary lesions in non-infarct-related arteries with an FFR of greater than 0.8 is safe and efficient.”
Serving as a discussant after Smits’ presentation, Nils Johnson, MD (University of Texas Health Science Center at Houston), said the trial is a major step forward in addressing how best to treat patients with acute STEMI and multivessel disease.
But he raised concerns regarding the benefits and costs…