FFR-Guided Complete versus Culprit-Only Revascularization in Patients With Myocardial Infarction: A Systematic Review and Meta-Analysis

Clinical Snapshot

Key Findings

• P Value: Not statistically significant (CI crosses 1.0)

• Effect Size: Risk ratio 0.63 favoring FFR-guided complete revascularization

• Primary Outcome: MACE (composite of all-cause death, MI, unplanned revascularization)

• Nnt Or Sensitivity: Significant reduction in unplanned revascularization (RR 0.43, 95% CI: 0.21-0.87)

• Confidence Interval: 95% CI: 0.37-1.05

Clinical Application

Requires FFR capability and expertise in catheterization laboratories, which may limit implementation in some centers Relevant to Australian practice where FFR is available through Medicare item numbers. Aligns with CSANZ guidelines supporting physiological assessment in multivessel disease Patients with acute MI and multivessel CAD suitable for FFR assessment during index hospitalization

Abstract

In patients with myocardial infarctions (MI) and multivessel coronary artery disease (CAD), the effect of fractional flow-reserve (FFR)-guided complete revascularization during index hospitalization versus culprit-only revascularization remains unclear. Our objective is to determine whether FFR-guided complete revascularization during index hospitalization reduces major adverse cardiac events (MACE) among patients with MI and multivessel CAD. We systematically searched MEDLINE, EMBASE, and the Cochrane Library for randomized controlled trials (RCTs) comparing FFR-guided complete versus culprit-only revascularization in patients with MI and multivessel CAD. The primary outcome was MACE, as defined by a composite endpoint of all-cause death, MI or unplanned revascularization, at a minimum 1-year follow-up. Count data were pooled across trials using random-effects models to estimate risk ratios (RRs) and 95% confidence intervals (CIs). A total of 3 RCTs (n = 3,054) were included. The majority (77.5%) of participants were male. The pooled RR of MACE for FFR-guide complete versus culprit-only revascularization was 0.63 (95% CI: 0.37-1.05; I2 = 90%). FFR-guided complete revascularization was associated with reduced unplanned revascularization events, with a pooled RR 0.43 (95% CI: 0.21-0.87; I2 = 88%). There was no significant difference in the risk of recurrent MI (RR: 0.9; 95% CI: 0.61-1.33; I2 =30%). The risk of major bleeding was low in both FFR-guided complete (23/1373) and culprit-only (29/1681) revascularization groups across the 3 trials. In conclusion, in patients with MI and multivessel CAD, FFR-guided complete revascularization during the index hospitalization reduces the risk of unplanned revascularizations and may reduce the risk of MACE compared to culprit-only revascularization.

References

1. 1.Seirafi, T., Zolotarova, T., Levett, J. Y., Angheluta, A. D., Filion, K. B., & Eisenberg, M. J. (2026). FFR-guided complete versus culprit-only revascularization in patients with myocardial infarction: A systematic review and meta-analysis. The American Journal of Cardiology. https://doi.org/10.1016/j.amjcard.2026.02.022