Immediate versus staged complete myocardial revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease: A post hoc analysis of the randomized FLOWER-MI trial - 10/11/22

Revascularisation myocardique immédiate versus différée chez les patients avec un infarctus avec sus décalage ST pluritronculaire : analyse post hoc de l’étude randomisée FLOWER-MI

Doi : 10.1016/j.acvd.2022.05.011

Victoria Tea ^a,^p, Jean-François Morelle ^b, Romain Gallet ^c,^q, Guillaume Cayla ^d,^e, Gilles Lemesle ^e,^f,^r, Thibault Lhermusier ^g,^s, Jean-Guillaume Dillinger ^e,^h, Grégory Ducrocq ^e,^i,^t,^u, Denis Angouvant ^e,^j, Yves Cottin ^k,^v, Chekrallah Chamandi ^a,^p, Alicia le Bras ^l, Philippe Gabriel Steg ^e,^i,^t,^u, Gilles Montalescot ^m, Anaïs Charles Nelson ⁿ, Tabassome Simon ^e,^o,^w,^x, Gilles Chatellier ⁿ, Nicolas Danchin ^a,^e,^p, Etienne Puymirat ^a,^e,^p,^⁎
for the FLOWER-MI study investigators
^a Department of Cardiology, Hôpital Européen Georges Pompidou, AP–HP, 75015 Paris, France
^b Clinique St. Martin, 14000 Caen, France
^c Service de cardiologie, Hôpitaux Universitaires Henri Mondor, AP–HP, 94000 Créteil, France
^d Centre Hospitalier Universitaire de Nîmes, 30900 Nîmes, France
^e French Alliance for Cardiovascular Trials (FACT), 75018 Paris, France
^f Cardiac Intensive Care Unit, CHU de Lille, 59000 Lille, France
^g Department of Cardiology, Intensive Cardiac Care Unit, Rangueil University Hospital, 31059 Toulouse, France
^h Department of Cardiology, Hôpital Lariboisière, AP–HP, Inserm U-942, Université de Paris, 75010 Paris, France
ⁱ Department of Cardiology, Hôpital Bichat, AP–HP, 75018 Paris, France
^j Cardiology Department, University Hospital of Tours, 37000 Tours, France
^k PEC2, EA 7460, University of Bourgogne Franche-Comté, 21000 Dijon, France
^l Clinical Research Unit Eco Île de France, Hôpital Hôtel Dieu, AP–HP, 75004 Paris, France
^m Sorbonne Université, ACTION Study Group, Institut de Cardiologie (AP–HP), Inserm UMRS 1166, Hôpital Pitié-Salpêtrière, 75013 Paris, France
ⁿ Clinical Research Unit and CIC 1418 Inserm, Hôpital Européen Georges Pompidou, AP–HP, 75015 Paris, France
^o Department of Clinical Pharmacology and Unité de Recherche Clinique (URCEST), Hôpital Saint Antoine, AP–HP, 75012 Paris, France
^p Université de Paris, 75006 Paris, France
^q U955-IMRB, Equipe 03, Inserm, Université Paris Est Creteil (UPEC), Ecole Nationale Vétérinaire D’Alfort (EnVA), 94700 Maisons-Alfort, France
^r Heart and Lung Institute, CHU de Lille, Institut Pasteur of Lille, Inserm U1011, 59000 Lille, France
^s Medical School, Toulouse III Paul Sabatier University, 31059 Toulouse, France
^t Inserm U1148, Laboratory for Vascular Translational Science, 75018 Paris, France
^u Université de Paris, 75005 Paris, France
^v Cardiology Department, University Hospital Centre of Dijon Bourgogne, 21000 Dijon, France
^w Université Pierre et Marie Curie (UPMC-Paris 06), 75005 Paris, France
^x Inserm U-698, 75012 Paris, France

^⁎Corresponding author at: Department of Cardiology, Hôpital Européen Georges Pompidou, 20, rue Leblanc, 75015 Paris, France.Department of Cardiology, Hôpital Européen Georges Pompidou20, rue LeblancParis75015France

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Graphical abstract

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Highlights

•	The optimal timing of revascularization of non-infarct related artery (IRA) in ST-elevation myocardial infarction (STEMI) with multivessel disease is debated.
•	Our trial show that staged non-IRA complete revascularization was the preferred strategy by operators.
•	This strategy was however not superior compared to an immediate revascularization in terms of major adverse cardiovascular events at one year.

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Abstract

Background

In patients with ST-segment elevation myocardial infarction and multivessel disease, percutaneous coronary intervention for non-culprit lesions is superior to treatment of the culprit lesion alone. The optimal timing for non-infarct-related artery revascularization – immediate versus staged – has not been investigated adequately.

Aim

We aimed to assess clinical outcomes at 1 year in patients with ST-segment elevation myocardial infarction with multivessel disease using immediate versus staged non-infarct-related artery revascularization.

Methods

Outcomes were analysed in patients from the randomized FLOWER-MI trial, in whom, after successful primary percutaneous coronary intervention, non-culprit lesions were assessed using fractional flow reserve or angiography during the index procedure or during a staged procedure during the initial hospital stay, ≤5 days after the index procedure. The primary outcome was a composite of all-cause death, non-fatal myocardial infarction and unplanned hospitalization with urgent revascularization at 1year.

Results

Among 1171 patients enrolled in this study, 1119 (96.2%) had complete revascularization performed during a staged procedure, and 44 (3.8%) at the time of primary percutaneous coronary intervention. During follow-up, a primary outcome event occurred in one of the patients (2.3%) with an immediate strategy and in 55 patients (4.9%) with a staged strategy (adjusted hazard ratio 1.44, 95% confidence interval 0.39–12.69; P=0.64).

Conclusions

Staged non-infarct-related artery complete revascularization was the strategy preferred by investigators in practice in patients with ST-segment elevation myocardial infarction with multivessel disease. This strategy was not superior to immediate revascularization, which, in the context of this trial, was used in a small proportion of patients. Further randomized studies are needed to confirm these observational findings.

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Keywords : Acute myocardial infarction, Fractional flow reserve, Multivessel disease

Abbreviations : CI, FFR, FLOWER-MI, HR, IRA, MACE, PCI, STEMI

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Vol 115 - N° 10

P. 496-504 - octobre 2022 Retour au numéro

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Immediate versus staged complete myocardial revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease: A post hoc analysis of the randomized FLOWER-MI trial - 10/11/22

Revascularisation myocardique immédiate versus différée chez les patients avec un infarctus avec sus décalage ST pluritronculaire : analyse post hoc de l’étude randomisée FLOWER-MI

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