Acute Coronary Syndromes (ACS), NSTEMI - Non-ST-Segment Elevation Myocardial Infarction, STEMI - ST Elevation Myocardial Infarction, Multivessel Coronary Artery Disease
Conditions
Keywords
Murray-law based Quantitative Flow Ratio (μFR), Non culprit vessel, Revascularization
Brief summary
Acute coronary syndromes (ACS) are frequently associated with multivessel coronary artery disease (CAD), and current guidelines recommend complete revascularization beyond the culprit lesion. Angiography-guided PCI is the standard approach, but anatomical assessment does not always reflect the functional significance of intermediate lesions, while FFR-guided strategies are limited by the need for pressure wires and hyperemia. Murray-law-based quantitative flow ratio (μFR) is a wire-free angiography-derived physiological index that may improve decision-making for revascularization in ACS patients. The Core-μFR is an investigator-driven, multicenter, randomized, open-label and prospective trial designed to evaluate whether μFR can act as a gatekeeper for complete revascularization in patients with ACS and multivessel disease by identifying non-culprit lesions that truly require PCI. Patients with ACS (either STEMI or NSTE-ACS) undergoing primary PCI will be considered eligible if they present multivessel CAD on visual assessment with the intention to treat the non-culprit vessel in a staged procedure within the same hospitalization. After the pPCI, eligible patients will be randomized to either group A or group B and μFR will be performed in a blinded fashion with the operator unaware of the functional result. Patients in group A will undergo a staged PCI of all NCVs guided by coronary angiography, as per standard of care. In group B, μFR will be used as a gatekeeper for staged revascularization. Operators will only be informed whether at least one non-culprit vessel is μFR-positive, without disclosure of the specific vessel involved or the μFR values. If at least one non-culprit vessel has μFR ≤0.80, patients will undergo angiography-guided PCI of all non-culprit vessels previously deemed suitable for treatment by visual assessment. If μFR is \>0.80 in all non-culprit vessels, staged PCI will be deferred and the patient will be discharged without further revascularization. Finally, to test the functional reproducibility, a blinded post-hoc μFR assessment will be performed on the baseline angiograms of the staged procedures in all the patients undergoing complete revascularization. Clinical follow-up will be performed at 30 days and 1 year from randomization.
Interventions
PROCEDUREAngiography-guided PCI
staged PCI of all NCVs will be performed as per standard of care
PROCEDUREμFR based-PCI
staged PCI will be deferred if the μFR \> 0.80 in all the NCVs or performed if the μFR is ≤ 0.80 in at least one NCVs
Sponsors
University of Roma La Sapienza
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Masking description
Complete revascularization will be performed with the operators blinded to the μFR results.
Eligibility
Sex/Gender
ALL
Healthy volunteers
No
Inclusion criteria
1. Patients presenting with ACS within 72 hours of successful culprit PCI 2. Residual coronary artery disease, defined as at least one additional stenosis in any non-culprit vessel (NCV) with the following characteristics: 1. at least 50% diameter stenosis by visual assessment 2. a vessel diameter of at least 2.5 mm 3. amenable to successful PCI
Exclusion criteria
1. Cardiogenic shock or severe heart failure (NYHA class ≥III) 2. Severely impaired renal function: creatinine \>2 mg/dl or estimated glomerular filtration rate (eGFR) \<30 ml/min/1,73 m² 3. Allergy to iodine-containing contrast agents which cannot be adequately pre-medicated 4. Pregnancy or intention to become pregnant during the trial 5. Life expectancy less than one year 6. Ambiguity in the identification of the culprit vessel/lesion 7. Clinical presentation as myocardial infarction and non-obstructive coronary artery disease (MINOCA) and/or Tako-Tsubo Syndrome 8. Any ambiguity in the diagnosis of ACS 9. Inability to provide informed consent 10. Patients with only one coronary artery lesion with diameter stenosis \>90% and/or TIMI flow \<3 11. Patients in whom the NCV is treated at the time of the index procedure 12. An interrogated lesion is at the site of a myocardial bridge 13. An interrogated lesion is a culprit lesion responsible for the acute myocardial infarction 14. An interrogated lesion is in a bypass graft 15. Poor angiographic image quality precluding vessel contour detection or with suboptimal contrast opacification 16. Severe vessel overlap in the stenosed segment or severe tortuosity of any interrogated vessel deemed not amenable to μFR measurement
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Primary efficacy endpoint | Periprocedural | Number of stents implanted and number of procedures |
| Primary safety endpoint | 1 year | MACE (major adverse cardiovascular event) defined as the composite of all-cause mortality, non-culprit vessel unplanned revascularization, non-fatal myocardial infarction (defined according to the Fourth Universal Definition of Myocardial Infarction, including procedural MI and spontaneous MI) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Inappropriate revascularization | Periprocedural | Inappropriate revascularization according to μFR value |
| Change in clinical decision making | Periprocedural | Change in clinical decision making about revascularization strategy from intended PCI to medical therapy |
| μFR reproducibility | Periprocedural | Test-re-test repeatability of μFR |
| Length of stay | Periprocedural | Duration of hospitalization |
Countries
Italy
Contacts
CONTACTEmanuele Barbato, MD, PhD
CONTACTEmanuele Gallinoro, MD, PhD
Outcome results
None listed