Myocardial ischemia and coronary artery disease (CAD) burden both provide valuable prognostic
information for adverse cardiac events. More than 50% of patients with acute myocardial
infarction have multi-vessel coronary artery disease. However current evidence regarding the
optimal treatment of the non-culprit lesions (NCL) after myocardial infarction (MI) is still
limited.
The revascularization of NCL with at least moderate severity is associated with improved
clinical outcomes, if significant ischemia was detected previously. Currently, there is no
strict recommendation on the methods for detecting ischemia, therefore the current study aims
to compare Dobutamine stress echocardiography (DSE) and invasive FFR for the evaluation and
management of patients with MI and multi-vessel disease.
DSE and FFR measurements will be perfomed in patinets with at least one intermediate NCL. If
both results are positive (new wall motion abnormality of at least two segments related to
the examined coronary artery on DSE and FFR≤0,8 are declared as positive), stent implantation
will be performed, if both results are negative or in case of mismatch, optimal medical
treatment will be chosen.
Recent studies demonstrated the discrepancy between anatomical severity and hemodynamic
relevance. Invasive fractional flow reserve (FFR) has emerged as the gold standard technique
for the detection of lesion specific ischemia. The utilization of FFR in stable and acute
chest pain patients can help in the selection of proper treatment strategy. The recently
published Compare-Acute and DANAMI-Primulti trials have shown that in STEMI patients
FFR-guided complete revascularization of NCL is beneficial as compared to infarct related
lesion revascularization only.
However, in light of recent studies involving post-MI patients, invasive FFR might be limited
for the assessment of NCL due to vessel remodeling, microvascular changes and altered
hemodynamics.
Recent advancements in CT imaging allows for improved image quality and novel post-processing
algorithms. Beyond anatomical data, functional information using coronary CT angiography
(CTA) dataset and computational fluid dynamics simulations can be derived. CT derived FFR
allows for the functional assessment of CAD in a non-invasive fashion.
Data regarding the diagnostic accuracy of CT-FFR as compared to other widely utilized
functional tests are limited. Also, high-risk plaque features might affect lesion specific
ischemia as detected by invasive FFR. Coronary CTA plus CT-FFR may help to identify patients
requiring revascularization, even with controversial DSE and FFR results.