Design and rationale of the COMPARE-ACUTE trial: Fractional flow reserve-guided primary multivessel percutaneous coronary intervention to improve guideline indexed actual standard of care for treatment of ST-elevation myocardial infarction in patients with multivessel coronary disease

Aims What the best strategy is for nonculprit lesions in ST-elevation myocardial infarction (STEMI) patients presenting with multivessel disease remains a clinical dilemma. Based on recent clinical studies suggesting that complete revascularization in the acute phase is beneficial, the European Society of Cardiology and American College of Cardiology/American Heart Association guidelines have been recently changed from class 3 discouragement to a class 2B recommendation concerning the treatment of the nonculprit lesions in the acute index procedure. However, in these recent studies, nonculprit lesion treatment was guided by angiography, which is known for its poor accuracy in determining ischemia. Fractional flow reserve (FFR) guidance for treatment of nonculprit vessels seems to be a reasonable approach, and in the acute setting of STEMI, it is not yet investigated. The COMPARE-ACUTE trial aims to investigate FFR-guided complete revascularization in comparison to a culprit lesion treatment-only strategy in STEMI patients with multivessel disease presenting for primary percutaneous coronary intervention. Methods and results COMPARE-ACUTE is an investigator-initiated, prospective multicenter randomized controlled trial. After successful primary percutaneous coronary intervention, patients will be randomized in a 1:2 fashion toward FFR-guided complete revascularization or culprit lesion treatment-only strategies. The chosen primary end point is a composite of all-cause mortality, nonfatal myocardial infarction, any revascularization, and cerebrovascular events (major adverse cardiac and cerebrovascular events) at 12 months, with 3-year follow-up. Based on estimated event rates, a sample size of 885 patients is needed to show superiority of the FFR-guided revascularization with 80% power. Conclusion The aim of the COMPARE-ACUTE trial is to assess whether FFR-guided complete revascularization in the acute setting is superior to culprit lesion treatment-only therapy.