FFR- Versus Angiography-Guided Revascularization for Nonculprit Stenosis in STEMI and Multivessel Disease: A Network Meta-Analysis

Ayman Elbadawi, Alexander T. Dang, Mohamed Hamed, Mennaallah Eid, Meghana Prakash Hiriyur Prakash, Mohammed Saleh, Mohamed Gad, Mamas A. Mamas, Faisal Rahman, Islam Y. Elgendy

Research output: Contribution to journalArticlepeer-review


Objectives: The aim of this study was to examine the efficacy and safety of fractional flow reserve (FFR)–guided versus angiography-guided approaches for nonculprit stenosis among patients with acute ST-segment elevation myocardial infarction (STEMI) and multivessel disease. Background: The optimal strategy to guide revascularization of nonculprit stenosis among patients with STEMI and multivessel disease remains uncertain. Methods: Electronic databases were searched for randomized trials evaluating the outcomes of culprit-only revascularization, angiography-guided complete revascularization (CR), or FFR-guided CR. A pairwise meta-analysis comparing CR versus culprit-only revascularization and a network meta-analysis comparing the different revascularization techniques were conducted. The primary outcome was major adverse cardiac events (MACE). Results: The analysis included 11 trials with 8,195 patients. CR (ie, angiography-guided or FFR-guided CR) was associated with a lower incidence of MACE (odds ratio [OR]: 0.46; 95% CI: 0.35 to 0.59), cardiovascular mortality (OR: 0.63; 95% CI: 0.41 to 0.98), recurrent myocardial infarction (OR: 0.67; 95% CI: 0.48 to 0.95), and repeat ischemia-driven revascularization (OR: 0.26; 95% CI: 0.19 to 0.35). Network meta-analysis demonstrated that the incidence of MACE was lower with both angiography-guided CR (OR: 0.43; 95% CI: 0.31 to 0.58) and FFR-guided CR (OR: 0.52; 95% CI: 0.35 to 0.78) compared with a culprit-only approach, while there was no difference in risk for MACE between angiography-guided and FFR-guided CR (OR: 0.81; 95% CI: 0.51 to 1.29). Conclusions: Among patients with STEMI and multivessel disease, CR, with angiographic or FFR guidance for nonculprit stenosis, was associated with lower incidence of adverse events compared with culprit-only revascularization. FFR-guided CR was not superior to angiography-guided CR in reducing the incidence of adverse events. Future studies investigating other tools to risk-stratify nonculprit stenoses are encouraged.

Original languageEnglish (US)
Pages (from-to)656-666
Number of pages11
JournalJACC: Cardiovascular Interventions
Issue number6
StatePublished - Mar 28 2022


  • FFR
  • angiography
  • complete revascularization
  • multivessel disease

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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