PCI for Nonculprit Lesions in Patients with STEMI — No Role for FFR

This editorial analyzes findings from the FLOWER-MI trial comparing fractional flow reserve (FFR)-guided versus angiography-guided PCI for nonculprit lesions in patients with STEMI and multivessel disease. The trial enrolled 1171 patients and found no significant difference in the composite outcome of death, myocardial infarction, or urgent revascularization at one year—occurring in 5.5% of the FFR group and 4.2% of the angiography group (HR: 1.32; 95% CI: 0.78–2.23). Although FFR guidance led to fewer interventions (PCI performed in 66% vs. 97%), the wide confidence intervals and a numerically higher rate of MI in the FFR arm suggest potential harm. The editorial underscores that unlike stable coronary disease, FFR offers no proven benefit in the post-STEMI setting for nonculprit lesion evaluation. It references prior trials, including COMPLETE and Compare-Acute, and recommends angiography-guided PCI as the preferred strategy. Guidelines should reflect this evidence and assign a Class I recommendation to angiography-based decisions in stable STEMI patients with multivessel disease.

This editorial analyzes findings from the FLOWER-MI trial comparing fractional flow reserve (FFR)-guided versus angiography-guided PCI for nonculprit lesions in patients with STEMI and multivessel disease. The trial enrolled 1171 patients and found no significant difference in the composite outcome of death, myocardial infarction, or urgent revascularization at one year—occurring in 5.5% of the FFR group and 4.2% of the angiography group (HR: 1.32; 95% CI: 0.78–2.23). Although FFR guidance led to fewer interventions (PCI performed in 66% vs. 97%), the wide confidence intervals and a numerically higher rate of MI in the FFR arm suggest potential harm. The editorial underscores that unlike stable coronary disease, FFR offers no proven benefit in the post-STEMI setting for nonculprit lesion evaluation. It references prior trials, including COMPLETE and Compare-Acute, and recommends angiography-guided PCI as the preferred strategy. Guidelines should reflect this evidence and assign a Class I recommendation to angiography-based decisions in stable STEMI patients with multivessel disease.