In order to bring you the best possible user experience, this site uses Javascript. If you are seeing this message, it is likely that the Javascript option in your browser is disabled. For optimal viewing of this site, please ensure that Javascript is enabled for your browser.
Did you know that your browser is out of date? To get the best experience using our website we recommend that you upgrade to a newer version. Learn more.

Hot Line - What is the best method to guide PCI for complete revascularisation after MI – FFR or angiography?

Percutaneous coronary intervention (PCI) of non-infarct-related artery (IRA) lesions for complete revascularisation improves clinical outcomes compared with IRA-only PCI in patients with STEMI and multivessel coronary artery disease (CAD).1,2 However, the most effective strategy for identifying appropriate targets to enable complete revascularisation has not been determined.

In a Hot Line session yesterday, Professor Joo-Yong Hahn (Samsung Medical Center - Seoul, Republic of Korea) presented findings from the FRAME-AMI trial, which compared the use of fractional flow reserve (FFR) with angiography to guide PCI in non-IRA lesions in this setting.

FRAME-AMI was an open-label investigator-led study conducted at 14 centres in Korea and enrolling patients with acute myocardial infarction (MI) and multivessel CAD (>50% diameter stenosis in a major epicardial coronary artery or major side branch with vessel diameter ≥2.0 mm by visual estimation). Following successful IRA PCI, patients were randomised 1:1 to receive FFR-guided PCI of non-IRA stenosis with FFR ≤0.80 or angiography-guided PCI of non-IRA stenosis (diameter >50%). Although complete revascularisation during the index procedure was recommended for all patients, staged procedures during the index hospitalisation were at the operators’ discretion. The primary endpoint was a composite of all-cause death, MI or unplanned revascularisation.

Between August 2016 and December 2020, 562 patients were randomised. The average age of patients was 63 years and 16% were women. Non-IRA lesions were treated by immediate PCI in 60% of patients and by staged procedure during the same hospitalisation in 40% of patients.

At a median follow up of 3.5 years, FFR was associated with a lower risk of the primary endpoint, which occurred in 18/284 patients in the FFR group and 40/278 patients in the angiography group (event rates at 4 years: 7.4% versus 19.7%; hazard ratio [HR] 0.43; 95% CI 0.25 to 0.75; p=0.003).

FFR was also associated with significantly fewer deaths than angiography (5 versus 16, respectively; event rates at 4 years: 2.1% versus 8.5%; HR 0.30; 95% CI 0.11 to 0.83; p=0.020) and a lower incidence of MI (7 versus 21, respectively; event rates at 4 years: 2.5% versus 8.9%; HR 0.32; 95% CI 0.13 to 0.75; p=0.009). Unplanned revascularisations were seen in 10 patients receiving FFR and in 16 undergoing angiography (KM event rates at 4 years, 4.3% versus 9.0%; HR 0.61; 95% CI 0.28 to 1.34; p=0.216).

“In patients with acute MI and multivessel CAD, using FFR to select non-IRA lesions for PCI was superior to selection of non-IRA lesions based on angiographic diameter stenosis regarding the risk of death, MI or repeat revascularisation,” says Prof. Hahn. “The benefit of FFR-guided PCI on the primary endpoint was consistent regardless of the type of MI (STEMI or non-STEMI).” He concludes: “Guidelines are unlikely to change solely based on the results of our trial, but in clinical practice, interventional cardiologists may choose to adopt FFR-guided decision making in patients with acute MI and multivessel disease.”


1. Gershlick AH, et al. J Am Coll Cardiol. 2015;65:963–972.

2. Mehta SR, et al. N Engl J Med. 2019;381:1411–1421.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.