Characterization of lesions undergoing ischemia-driven revascularization after complete revascularization versus culprit lesion only in patients with STEMI and multivessel disease - A DANAMI-3-PRIMULTI substudy.

AIMS: Treatment of the infarct-related artery only (IRA-only) in ST-segment elevation myocardial infarction (STEMI) is associated with a significantly higher rate of ischemia-driven revascularization (ID-RV) during follow-up than fractional flow reserve-guided complete revascularization (FFR-CRV).

METHODS AND RESULTS: In this study, we characterized the lesions that underwent ID-RV in the DANAMI-3-PRIMULTI-trial (n=627) with respect to location, angiographic diameter stenosis and functional significance. Rates of admission for suspected cardiac ischemia (17%) were similar in both groups; however, ID-RV was significantly less frequent in the FFR-CRV group than in the IRA-only group (5% vs. 17%; p<0.001). In both groups, the primary reason for ID-RV were non-culprit, non-treated lesions (N=71/82 lesions in IRA-only; N=13/26 in FFR-CRV). De-novo lesions or revascularization of previously treated lesions were rarely causes of ID-RV. In the IRA-only group, there was a trend towards a higher ID-RV-rate for lesions with a higher stenosis grade and located in more proximal segments - in particular ≥80% stenosis of left anterior descending and right coronary artery also led to angina class IV/unstable angina. In the FFR-CRV group, a FFR-value ≤0.80 showed to be an appropriate threshold for revascularization.

CONCLUSIONS: FFR-CRV in STEMI is associated with a significantly lower rate of ID-RV at follow-up than treatment of the IRA-only - this due to a difference in non-culprit, non-treated lesions between both groups and not in de-novo lesions or repeat revascularization of previously treated lesions. Further considerations are warranted in case of high-grade non-culprit stenosis at proximal coronary segments, borderline FFR-values and/or anticipated complex PCI.