Fractional Flow Reserve-Guided Complete vs Culprit-Only Revascularization in Non-ST-Elevation Myocardial Infarction and Multivessel Disease: The SLIM Randomized Clinical Trial.

Summary

In this multicenter RCT of NSTEMI with multivessel disease (n=478), FFR-guided complete revascularization during the index procedure reduced the 1-year composite of all-cause death, nonfatal MI, any revascularization, and stroke vs culprit-only PCI (5.5% vs 13.6%; HR 0.38). Benefits were mainly driven by fewer repeat revascularizations and lower NACE; other secondary outcomes were similar.

Key Findings

• Primary composite endpoint at 1 year: 5.5% (complete) vs 13.6% (culprit-only); HR 0.38 (95% CI 0.20–0.72), p=0.003
• Lower any revascularization: 3.0% vs 11.5%; HR 0.24 (95% CI 0.11–0.56), p<0.001
• Lower net adverse clinical events (NACE): 6.3% vs 15.3%; HR 0.39 (95% CI 0.21–0.70), p=0.002

Clinical Implications

Consider FFR-guided complete revascularization at index PCI for NSTEMI with multivessel disease to reduce 1-year adverse events, particularly repeat revascularization, when anatomy and clinical status permit.

Limitations

• Modest sample size; primary benefit driven by fewer revascularizations rather than mortality
• Open-label design; operator blinding not feasible; generalizability beyond trial centers uncertain

Future Directions

Larger trials powered for hard outcomes (death/MI) and cost-effectiveness analyses of FFR-guided complete revascularization in NSTEMI are warranted.