Page 162 - Coronary hemodynamics in acute myocardial infarction - Matthijs Bax

Chapter 9
disease in STEMI patients roughly has three different approaches: angiography, optical coherence tomography (OCT) and invasive coronary physiology assessment. The COMPLETE (Complete vs Culprit-only Revascularization to Treat Multi-vessel Disease After Early PCI for STEMI) trial suggests complete revascularization in STEMI patients with multivessel disease based on angiography, independent of infarct size.26 A sub study of the COMPLETE trial and several other studies suggest OCT assessment of obstructive non-culprit lesions containing complex vulnerable plaque morphology and subsequent treatment of these lesions.27–29 Coronary physiology assessment by using Fractional Flow Reserve (FFR) in STEMI patients with multivessel disease has been evaluated in several trials, and showed a decrease in major adverse cardiac events for FFR-guided PCI of the non-culprit; however, this effect is mainly driven by the complete revascularization at baseline and subsequent prevention of inevitable revascularization at a later stadium.30,31 Additionally, non-culprit instantaneous wave-free ratio (iFR) has been assessed in the iSTEMI trial, during the acute ischaemic event and ≥16 days post-STEMI. iFR was significantly lower during the acute ischaemic event compared with follow-up, potentially due to a higher baseline flow in the setting of STEMI, resulting in a potential overtreatment of these lesions compared with FFR.32 The ongoing trials iModern (iFR Guided Multi-vessel Revascularization During Percutaneous Coronary Intervention for Acute Myocardial Infarction, NCT03298659) and FRAME-AMI (FFR Versus Angiography-Guided Strategy for Management of AMI With Multivessel Disease, NCT02715518) both evaluate non-culprit lesions with iFR and/or FFR in the setting of AMI. However, certainly FFR, and potentially to a lesser extent iFR, are affected by the coronary microcirculation and microvascular resistance in particular, so these indices have to be interpreted cautiously if these are assessed in the setting of STEMI.33,34 On the contrary, non-culprit vessel CFR has important prognostic value as reflected by a 4.09- fold increase in long-term cardiac mortality if non-culprit vessel CFR <2.0 in STEMI patients with multivessel disease.11 Non-culprit vessel CFC assessment post primary PCI of the culprit has a significant benefit to determine long term prognosis and clinical outcome. Hence, patients with lower CFC in the non- culprit vessel after primary PCI of the culprit in the setting of STEMI require more intensive treatment and monitoring.
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