The benefit of physiology-guided complete revascularization in patients presenting with myocardial infarction (MI) remains uncertain. Data from earlier studies, such as the COMPLETE (Complete Versus Culprit-Only Revascularization Strategies to Treat Multivessel Disease After Early PCI for STEMI) and FIRE (Functional Assessment in Elderly MI Patients With Multivessel Disease) trials,^1,2 showed a reduction in the rates of cardiovascular death and MI with complete revascularization; however, the COMPLETE trial evaluated angiography and the FIRE trial evaluated an older (≥75 years of age) patient population. The FULL REVASC (FFR-Guidance for Complete Nonculprit Revascularization) investigators aimed to assess whether patients with ST-segment elevation myocardial infarction (STEMI) or very-high-risk non–ST-segment elevation myocardial infarction (NSTEMI) and concomitant multivessel disease would benefit from fractional flow reserve (FFR)–guided percutaneous coronary intervention (PCI) of nonculprit lesions.³

In this parallel blinded study, 1,542 patients (mean age 65 years) with STEMI or very-high-risk NSTEMI were randomized to undergo FFR-guided complete revascularization or culprit-only PCI. At a median follow-up of 4.8 years, there was no significant difference in the composite primary outcome of death, MI, or unplanned revascularization (hazard ratio, 0.93; 95% confidence interval, 0.74-1.17; p = 0.53), or in any of these individual components.

The FULL REVASC trial was designed to guide FFR-guided revascularization but yielded neutral results. Despite the large sample size recruited, only 300 events occurred, leading to a lower-than-planned power of 74%. Furthermore, only 9% of patients presented with very-high-risk NSTEMI, and <50% of the FFR-measured nonculprit vessels had FFR ≤0.8. However, in the COMPLETE trial, 99% of nonculprit vessels had angiographically significant stenoses (≥70%) with <1% evaluated by FFR, which may have led to a higher percentage of lesions treated. Complete revascularization is likely to benefit this patient population. However, for those presenting with higher-risk MI, the FULL REVASC trial data suggest that complete revascularization can be safely deferred unless patients return with angina despite optimal medical therapy. Clinicians await the results of the COMPLETE-2 (Physiology-Guided Versus Angiography-Guided Complete Revascularization to Treat Multivessel Disease After Early PCI for STEMI) trial, which may provide more definitive evidence regarding physiology-guided PCI of nonculprit vessels in patients presenting with MI.

References

1. Mehta SR, Wang J, Wood DA, et al.; COMPLETE Trial Investigators. Complete revascularization vs culprit lesion-only percutaneous coronary intervention for angina-related quality of life in patients with ST-segment elevation myocardial infarction: results from the COMPLETE randomized clinical trial. JAMA Cardiol 2022;7:1091-9.
2. Biscaglia S, Guiducci V, Escaned J, et al.; FIRE Trial Investigators. Complete or culprit-only PCI in older patients with myocardial infarction. N Engl J Med 2023;389:889-98.
3. Böhm F, Mogensen B, Engstrøm T, et al.; FULL REVASC Trial Investigators. FFR-guided complete or culprit-only PCI in patients with myocardial infarction. N Engl J Med 2024;390:1481-92.