Clinical relevance of FFR-guided PCI according to LVEF in patients with AMI and multivessel disease

Fractional flow reserve (FFR) or angiography-guided complete revascularization is not evaluated in acute myocardial infarction (AMI) patients with multivessel disease and reduced left ventricular ejection fraction (LVEF).

To evaluate impact of FFR-guided percutaneous coronary intervention (PCI) for AMI patients with multivessel disease according to left ventricular systolic function.

We performed a pre-specified analysis of the FRAME-AMI 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 artery (IRA). Patients were classified into preserved (≥50%) and reduced (<50%) LVEF groups. Primary end point was major adverse cardiovascular events (MACEs), a composite of death, MI, and repeat revascularization.

Overall, 187 patients (33.3%) had reduced LVEF. During a median 3.5-year follow-up, AMI patients with reduced LVEF showed an increased risk of MACEs compared to those with preserved LVEF (P<0.001). FFR-guided PCI for non-IRA significantly reduced MACEs among preserved LVEF patients (3.3% vs. 19.0%; adjusted HR=0.23, 95% CI=0.09-0.59, P=0.002). Conversely, there was no significant difference in MACEs between the FFR and angiography-guided PCI among reduced LVEF patients (17.0% vs. 21.0%; HR=0.64, 95% CI=0.31-1.32, P=0.227). The clinical benefit of FFR-guided PCI was more evident with an increased LVEF (interaction P=0.028).

In AMI patients with multivessel disease, FFR-guided PCI for non-IRA 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.