FFR-guided complete revascularization vs culprit-only primary PCI among hemodynamically stable STEMI patients with multivessel disease: a meta-analysis

Abstract Introduction Preventive stenting of non-infarct-related arteries decreased the occurrence of combined cardiovascular deaths and myocardial infarction after successful primary PCI in patients with STEMI. Most studies investigated revascularizing non-culprit lesions based on visual estimation of stenosis severity by angiography alone. However, solely relying on coronary angiographic appearance can sometimes misjudge the functional impact of a lesion, potentially causing overtreatment. Purpose To investigate the outcomes of added FFR to guide revascularization of non-infarct-related arteries in patients presenting with STEMI and multivessel disease. Methods PubMed, Cochrane, and Embase databases were systematically searched for randomized controlled trials from 2003 until 31 September 2024. The primary outcome of interest was a composite of major adverse cardiovascular events. Results The search yielded 3 randomized controlled trials. The total number of patients included was 3,054 (FFR-guided complete revascularization = 1,373; culprit-only PCI = 1,681). Our pooled estimates showed that FFR-guided CR was associated with statistically significant lower MACE (RR 0.67, 95% CI -0.46-0.96, p 0.03, I2= 84%) and urgent revascularization (RR 0.61, 95% CI 0.41-0.89, p 0.01, I2= 48%) compared with culprit-only PCI. However, there was no significant difference in terms of all-cause mortality (RR 1.08, 95% CI 0.82-1.41, p = 0.71, I2 = 0%) and MI (RR 0.95, 95% CI 0.73-1.24, p = 0.71, I2 = 0%) between the two groups. Conclusion FFR-guided complete revascularization potentially leads to better outcomes compared to culprit-only PCI in hemodynamically stable STEMI patients with multivessel disease during index hospitalization. Our analysis supports adding FFR guidance to direct revascularization decisions for non-culprit lesions in this setting.