Clinical Outcome Following Conservative vs Revascularization Therapy in Patients With Stable Coronary Artery Disease and Borderline Fractional Flow Reserve Measurements

Abstract

Background: Fractional flow reserve (FFR) measurements in the so-called gray-zone range of 0.75 and 0.80 are associated with uncertainty concerning the guidance of patient therapy. It is unclear whether any difference in clinical outcome exists when revascularization treatment of FFR-evaluated lesions in this borderline range is deferred or performed. The objective of this study is to compare the clinical outcome of these patients with respect to their recommended treatment strategy. Methods: Out of a single center database of 900 consecutive patients with stable coronary artery disease, 97 patients with borderline FFR measurements were identified and included in the study. The rate of major adverse cardiac events (MACE; cardiac death, myocardial infarction (MI), coronary revascularization) and the presence of angina were evaluated at follow-up. Results: A total of 48 patients were deferred from revascularization and 49 patients underwent revascularization. There was no difference in risk profile between these groups. At a mean follow-up of 24 ± 16 months, event-free survival in the deferred group was significantly better regarding overall MACE, combined rate of cardiac death, and MI, as well as MACE related to the FFR-evaluated vessel. No difference with regard to the presence of angina was observed. Conclusions: Patients with coronary lesions in the borderline FFR range can be deferred from revascularization without putting them at increased risk for major adverse events. Revascularization may be considered in the course of therapy on an individual basis if typical angina persists or worsens despite maximal medical treatment.

Long-Term Outcome After Deferral of Revascularization in Patients With Intermediate Coronary Stenosis and Gray-Zone Fractional Flow Reserve

“…25 In contrast, Lindstaedt et al showed that patients with coronary lesions with gray-zone FFR 0.75-0.80 could have safe deferral of revascularization, and that the deferral strategy resulted in better outcome than the revascularization strategy. 26 The present study showed that the coronary lesions with FFR 0.75-0.80 were highly associated with TVF during 3-year follow-up in comparison with those with FFR >0.80. Most of the TVF, however, consisted of TVR due to progression of myocardial ischemia, and there was only 1 case of cardiac death and no cases of MI related to the target lesion.…”

Advances in three-dimensional coronary imaging and computational fluid dynamics

“…Invasive FFR served as the reference standard. The clinical cut-off value of 0.80 or less was used in accordance with established guidelines [41][42][43]. Patients with angina or non-ST-elevation myocardial infarction were included.…”

“…A total of 1005 patients with more than 50%DS in more than two epicardial coronary arteries were recruited. The FAME trial utilized a higher cut-off FFR value of 0.80 or less to include patients within the uncertainty region (0.75 ≤ FFR ≤ 0.80) as multiple studies have shown that there is an increased risk of ischaemia within these FFR values [41,42]. FFR value of 0.80 or less has since become the clinical cut-off value most often used [43].…”

Response to Impact of Lesion Length on Functional Significance in Intermediate Coronary Lesions

“…The FFR value in the functional severity of coronary artery stenoses has become a necessary tool for clinical decision making in catheterization laboratories recently. 2 FFR measurement also has been used to assess optimal percutaneous coronary intervention (PCI) results for prediction of favorable long-term clinical outcomes. FFR-guided PCI was associated with favorable outcomes in bifurcation lesions with native side branch vessels blocked by stent implantation.…”