Ankur Gupta1, Navkaranbir S Bajaj1, Pankaj Arora2, Garima Arora3, Arman Qamar1, Deepak L Bhatt4. 1. Heart and Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. 2. Division of Cardiovascular Disease, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA; Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA. 3. Division of Cardiovascular Disease, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA. 4. Heart and Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. Electronic address: dlbhattmd@post.harvard.edu.
Abstract
BACKGROUND: Randomized controlled trials (RCTs) have shown fractional flow reserve-guided (FFR) multivessel stenting to be superior to infarct-related artery (IRA) only stenting in patients with ST-elevation myocardial infarction (STEMI) and multivessel disease. This effect was mainly driven by a reduction in overall repeat revascularization. However, the ability to assess the effect of this strategy on urgent revascularization or reinfarction was underpowered in individual trials. METHODS: We searched Pubmed, EMBASE, Cochrane CENTRAL, and Web of Science for RCTs of FFR-guided multivessel stenting versus IRA-only stenting in STEMI with multivessel disease. The outcomes of interest were death, reinfarction, urgent, and non-urgent repeat revascularization. Risk ratios (RR) were pooled using the DerSimonian and Laird random-effects model. RESULTS: After review of 786 citations, 2 RCTs were included. The pooled results demonstrated a significant reduction in the composite of death, reinfarction, or revascularization in the FFR-guided multivessel stenting group versus IRA-only stenting group (RR [95%, Confidence Interval]: 0.49 [0.33-0.72], p<0.001). This risk reduction was driven mainly by a reduction in repeat revascularization, both urgent (0.41 [0.24-0.71], p=0.002) and non-urgent revascularization (0.31 [0.19-0.50], p<0.001). Pooled RR for reinfarction was lower in the FFR-guided strategy, but was not statistically significant (0.71[0.39-1.31], p=0.28). CONCLUSIONS: This systematic review and meta-analysis suggests that a strategy of FFR-guided multivessel stenting in STEMI patients reduces not only overall repeat revascularization but also urgent revascularization. The effect on reinfarction needs to be evaluated in larger trials.
BACKGROUND: Randomized controlled trials (RCTs) have shown fractional flow reserve-guided (FFR) multivessel stenting to be superior to infarct-related artery (IRA) only stenting in patients with ST-elevation myocardial infarction (STEMI) and multivessel disease. This effect was mainly driven by a reduction in overall repeat revascularization. However, the ability to assess the effect of this strategy on urgent revascularization or reinfarction was underpowered in individual trials. METHODS: We searched Pubmed, EMBASE, Cochrane CENTRAL, and Web of Science for RCTs of FFR-guided multivessel stenting versus IRA-only stenting in STEMI with multivessel disease. The outcomes of interest were death, reinfarction, urgent, and non-urgent repeat revascularization. Risk ratios (RR) were pooled using the DerSimonian and Laird random-effects model. RESULTS: After review of 786 citations, 2 RCTs were included. The pooled results demonstrated a significant reduction in the composite of death, reinfarction, or revascularization in the FFR-guided multivessel stenting group versus IRA-only stenting group (RR [95%, Confidence Interval]: 0.49 [0.33-0.72], p<0.001). This risk reduction was driven mainly by a reduction in repeat revascularization, both urgent (0.41 [0.24-0.71], p=0.002) and non-urgent revascularization (0.31 [0.19-0.50], p<0.001). Pooled RR for reinfarction was lower in the FFR-guided strategy, but was not statistically significant (0.71[0.39-1.31], p=0.28). CONCLUSIONS: This systematic review and meta-analysis suggests that a strategy of FFR-guided multivessel stenting in STEMI patients reduces not only overall repeat revascularization but also urgent revascularization. The effect on reinfarction needs to be evaluated in larger trials.
Authors: Duk-Woo Park; Robert M Clare; Phillip J Schulte; Karen S Pieper; Linda K Shaw; Robert M Califf; E Magnus Ohman; Frans Van de Werf; Sameer Hirji; Robert A Harrington; Paul W Armstrong; Christopher B Granger; Myung-Ho Jeong; Manesh R Patel Journal: JAMA Date: 2014-11-19 Impact factor: 56.272
Authors: A Ghani; J-H E Dambrink; A W J van 't Hof; J P Ottervanger; A T M Gosselink; J C A Hoorntje Journal: Neth Heart J Date: 2012-09 Impact factor: 2.380
Authors: Jan-Henk E Dambrink; Jan P Debrauwere; Arnoud W J van 't Hof; Jan-Paul Ottervanger; A T Marcel Gosselink; Jan C A Hoorntje; Menko-Jan de Boer; Harry Suryapranata Journal: EuroIntervention Date: 2010-04 Impact factor: 6.534
Authors: Pieter C Smits; Mohamed Abdel-Wahab; Franz-Josef Neumann; Bianca M Boxma-de Klerk; Ketil Lunde; Carl E Schotborgh; Zsolt Piroth; David Horak; Adrian Wlodarczak; Paul J Ong; Rainer Hambrecht; Oskar Angerås; Gert Richardt; Elmir Omerovic Journal: N Engl J Med Date: 2017-03-18 Impact factor: 91.245
Authors: Bernard De Bruyne; William F Fearon; Nico H J Pijls; Emanuele Barbato; Pim Tonino; Zsolt Piroth; Nikola Jagic; Sven Mobius-Winckler; Gilles Rioufol; Nils Witt; Petr Kala; Philip MacCarthy; Thomas Engström; Keith Oldroyd; Kreton Mavromatis; Ganesh Manoharan; Peter Verlee; Ole Frobert; Nick Curzen; Jane B Johnson; Andreas Limacher; Eveline Nüesch; Peter Jüni Journal: N Engl J Med Date: 2014-09-01 Impact factor: 91.245
Authors: David S Wald; Joan K Morris; Nicholas J Wald; Alexander J Chase; Richard J Edwards; Liam O Hughes; Colin Berry; Keith G Oldroyd Journal: N Engl J Med Date: 2013-09-01 Impact factor: 91.245
Authors: Anthony H Gershlick; Jamal Nasir Khan; Damian J Kelly; John P Greenwood; Thiagarajah Sasikaran; Nick Curzen; Daniel J Blackman; Miles Dalby; Kathryn L Fairbrother; Winston Banya; Duolao Wang; Marcus Flather; Simon L Hetherington; Andrew D Kelion; Suneel Talwar; Mark Gunning; Roger Hall; Howard Swanton; Gerry P McCann Journal: J Am Coll Cardiol Date: 2015-03-17 Impact factor: 24.094
Authors: Gani Bajraktari; Ibadete Bytyçi; Michael Y Henein; Fernando Alfonso; Ali Ahmed; Haki Jashari; Deepak L Bhatt Journal: Int J Cardiol Heart Vasc Date: 2020-06-13