FLOWER-MI Trial 2021

 The trial's purpose was to compare full revascularization guided by fractional flow reserve (FFR) vs angiography in patients with ST-segment elevation myocardial infarction (STEMI) who underwent PCI of their culprit artery.


Design of the Study


Patients with non-culprit multivessel coronary disease who underwent initial PCI for STEMI were randomized to FFR-guided revascularization (n = 590) or angiography-guided revascularization (n = 581).


The total number of enrollees was 1,171.

The duration of the follow-up was 12 months.

The average patient age was 63 years.

15% of the population was female.

Type 2 diabetes:  18% of the population.


Criteria for inclusion:


STEMI patients with multivessel non-culprit coronary disease


Criteria for exclusion:


Single-vessel coronary artery disease

Instability of the heart

Previously performed coronary artery bypass grafting

Calcification of the coronary arteries

Chronic complete occlusion



Important Findings:


At 12 months, the primary outcome of mortality, MI, or urgent revascularization occurred in 5.5 percent of the FFR-guided group versus 4.2 percent of the angiography-guided group (p = 0.31).



FFR-guided revascularization was not superior to angiography-guided revascularization in patients who received primary PCI for STEMI and had nonculprit multivessel coronary disease.


When compared to an angiography-guided strategy, an FFR-guided strategy failed to minimize the composite result of mortality, MI, or urgent revascularization.


For STEMI patients with multivessel coronary disease, current recommendations indicate that full revascularization should be considered during the index hospitalization.


According to the findings of this study, either an FFR-guided or an angiography-guided strategy for the management of remaining coronary artery disease after primary PCI is an acceptable option.


This was a well-designed experiment that showed that using fractional flow reserve (FFR) to guide additional non-culprit arterial revascularization in STEMI patients who underwent primary PCI was no better than plain old angiography (POBA).


It was reasonable to expect that FFR would improve outcomes, as it had in the case of stable coronary artery disease (CAD), but event rates were modest and did not improve with FFR use.


STEMI is, of course, not the same as stable CAD. STEMI patients are more likely to have plaques that are prone to rupture than patients with stable CAD.


As a result, more complete revascularization, even of lesions that appear angiographically severe but do not cause ischemia per se, may be beneficial.


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