April 2024: FFR-Guided Complete or Culprit-Only PCI in Patients with Myocardial Infarction
The issue
A large international trial (FULL REVASC) found that giving heart‑attack patients multivessel stenting guided by fractional‑flow‑reserve (FFR) did not lower deaths, repeat heart attacks, or urgent revascularizations versus treating only the blocked “culprit” artery (19.0 % vs 20.4 %; hazard ratio 0.93, P = 0.53).
What do I need to know?
The study followed 1,542 adults (mean age 65) with ST‑elevation or very‑high‑risk non‑STEMI and multivessel disease. Over 4.8 years, the “complete‑revascularization” strategy placed more stents yet yielded no survival benefit and actually produced higher rates of stent thrombosis and restenosis than culprit‑only PCI. Almost half of supposedly “tight” non‑culprit lesions had normal FFR (> 0.80) and were deferred, underscoring how physiologic testing can avoid unnecessary hardware. Guidelines now view routine multivessel PCI in older infarct patients as optional; individualized decisions that weigh frailty, bleeding risk, kidney function, and patient goals are critical.
Potential risk of overtreatment after a heart attack
An older adult has a recent MI, but additional artery narrowings are mild or of uncertain significance.
Recommended Actions
Ask whether FFR or another physiologic test has been done to confirm the importance of each narrowing.
Ensure guideline‑directed medicines (dual antiplatelet therapy, statin, β‑blocker, ACE‑inhibitor/ARB) are optimized.
Schedule cardiac rehab and lifestyle counseling before considering more stents.
Imminent risk of overtreatment
The patient has multivessel disease identified during the index PCI and clinicians are deciding on further stenting.
Recommended Actions
Request a geriatric/cardiology consult to weigh frailty, bleeding tendency, kidney function, and life expectancy.
Compare expected gains (fewer future procedures) with risks (extra contrast, stent thrombosis, restenosis).
Clarify whether non‑culprit PCI would be done immediately or in a separate procedure and how soon.
Confirmed need for additional revascularization
Recurrent angina, ischemia on testing, or severe, symptomatic non‑culprit stenosis.
Recommended Actions
Proceed with FFR‑guided PCI only for vessels clearly causing ischemia or symptoms.
Use radial access, low‑contrast techniques, and proton‑pump inhibitors to reduce bleeding and kidney injury.
Arrange close follow‑up within two weeks to adjust medications and monitor for stent complications.
What can I do?
Tell the heart team, “Am I at potential, imminent, or confirmed risk that justifies more stents, or is medical therapy enough?” Bring a current medication list, kidney‑function labs, and any symptoms diary. Understand that culprit‑only PCI plus optimal medicines is often sufficient; more stents do not automatically mean a longer life. If further PCI is planned, ask that it be done promptly rather than after a long hospital wait, and confirm a plan to monitor for stent thrombosis, kidney injury, and bleeding at every follow‑up.
