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Similar outcomes with fractional flow reserve and angiography-guided revascularisation

Presented by
Dr Etienne Puymirat, Hôpital Européen Georges-Pompidou
Conference
ACC 2021
Trial
FLOWER-MI
Fractional flow reserve (FFR)-guided revascularisation did not demonstrate benefit over angiography-guided revascularisation in the FLOWER-MI trial [1,2]. In patients with ST-elevated myocardial infarction (STEMI) and multivessel disease (MVD), complete revascularisation is associated with better clinical outcomes than culprit lesion only revascularisation. However, it remained unclear whether FFR could be useful in guiding revascularisation of non-culprit lesions in STEMI patients with MVD.

Angiography-based visual assessment of the degree of coronary artery stenosis is not a reliable indicator of haemodynamically significant obstruction; therefore, FFR can help guide appropriate decisions regarding percutaneous coronary intervention (PCI) of those vessels with significant lesions. However, trials investigating the use of FFR-guided revascularisation in patients with STEMI and MVD were lacking. To this end, the FLOWER-MI study (NCT02943954) randomised 1,163 patients to either angiography-guided PCI (n=577) or FFR-guided PCI (n=586). The study enrolled participants with STEMI who had undergone successful PCI and were judged to have at least 1 additional non-culprit lesion for which revascularisation could be recommended.

The primary outcome was the rate of major adverse cardiovascular events (i.e. composite of all-cause mortality, non-fatal myocardial infarction, and unplanned hospitalisation resulting in urgent revascularisation) at 1 year. This outcome occurred in 32 (5.5%) participants in the FFR arm and 24 (4.2%) participants in the angiography arm, yielding a hazard ratio of 1.32 (95% CI 0.78–2.23; P=0.31) (see Figure).

Figure: Primary outcome (MACE at 1 year) in the FLOWER-MI trial. Adapted from [2]

Angio, angiography; CI, confidence interval; HR, hazard ratio; FFR, fractional flow reserve; MACE, major adverse cardiac events; PCI, percutaneous coronary intervention.


These results failed to demonstrate a benefit of FFR-guided revascularisation over angiography-guided revascularisation in patients with STEMI and MVD in reducing major adverse cardiovascular events. However, the researchers caution that the wide confidence interval precludes any definitive conclusions.


    1. Puymirat E. Fractional Flow Reserve-guided Versus Angio-guided Multivessel Revascularization In ST-Elevation Myocardial Infarction Patients. The FLOWER-MI Randomised Trial. Abstract 407-08, ACC 2021 Scientific Session, 15–17 May.
    2. Puymirat E. N Engl J Med 2021;May 16. DOI:10.1056/NEJMoa2104650.

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