Determinants of suboptimal functional revascularization after primary PCI in STEMI: a prospective cohort study
B Tas Ozbek, J M M Jasmine Melissa Marqvard, Y Z Yan Zhou, C G Charlotte Glinge, M S Muhammad Sabbah, U I Ustho Islam, L H Lene Holmvang, R S Rikke Sorensen, O A Ole Ahlehoff, R J Reza Jabbari, M M Mikko Joonas Tapani Minkkinen, A I Allan Zeeberg Iversen, N O Niels Thue Olsen, T E Thomas Engstrom, J L Jacob Thomsen LonborgAbstract
Background
Primary percutaneous coronary intervention (PCI) is the standard treatment for ST-segment elevation myocardial infarction (STEMI). However, angiographic success PCI does not necessarily reflect normalization of coronary physiology, and residual ischemia may persist. Post-PCI fractional flow reserve (FFR) is well-established method for evaluating suboptimal revascularization. We aimed to evaluate impaired culprit lesion revascularization in patients treated with primary PCI.
Purpose
To evaluate the prevalence and determinants of suboptimal functional revascularization, defined by post-PCI FFR ≤0.89, in STEMI patients treated with primary PCI.
Method
In this prospective cohort study, STEMI patients underwent planned follow-up coronary angiography approximately 9 months after index PCI to evaluate residual epicardial disease, when acute microvascular dysfunction is expected to have resolved. Invasive physiological assessment included resting full-cycle ratio (RFR), FFR, and hyperaemic pressure pullback recordings with calculation of the pressure pullback gradient (PPG). Suboptimal functional revascularization was defined as post-PCI FFR ≤0.89.
Results
Of 126 enrolled patients, post-PCI FFR was available in 122. At follow-up, 54 (44%) patients demonstrated suboptimal FFR (≤0.89). In adjusted analyses, increasing age (odds ratio (OR) 1.06 per year increase, 95% CI 1.02–1.11, p=0.009); anterior infarction (OR 11.96, 95% CI 4.84–32.73, p<0.001) and left anterior descending (LAD) as the culprit vessel (OR 13.92, 95% CI 5.50–39.65, p<0.001) were independently associated with higher risk of suboptimal FFR. Higher admission LVEF (OR 0.96 per % increase, 95% CI 0.92–1.00, p=0.038) and larger stent diameter (OR 0.18 per mm increase, 95% CI 0.06–0.46, p<0.001) were associated with lower risk of suboptimal FFR (Figure 1). Traditional cardiovascular risk factors, lesion complexity, intravascular ultrasound use and time from symptom onset to wire were not associated with post-PCI physiological impairment.
Conclusion
Nearly half of STEMI patients demonstrate incomplete functional revascularization at follow-up despite apparently successful PCI. Suboptimal FFR appears to be mainly related to age, infarct-related territory (LAD) and luminal dimensions (stent diameter), rather than procedural factors.Figure 1For image description, please refer to the figure legend and surrounding text.