Diagnostic Classification of the Instantaneous Wave-Free Ratio Is Equivalent to Fractional Flow Reserve and Is Not Improved With Adenosine Administration

Sen, Sayan; Asrress, Kaleab; Nijjer, Sukhjinder; Petraco, Ricardo; Malik, Iqbal; Foale, Rodney A.; Mikhail, Ghada; Foin, Nicolas; Broyd, Christopher; Hadjiloizou, Nearchos; Sethi, Amarjit Singh; Al-Bustami, Mahmud; Hackett, D.; Khan, Masood; Khawaja, Muhammed Zeeshan; Baker, Christopher; Bellamy, Michael; Parker, Kim H.; Hughes, Alun D.; Francis, Dárrel P.; Mayet, Jamil; Mario, Carlo Di; Escaned, Javier; Redwood, Simon; Davies, Justin E.

doi:10.1016/j.jacc.2013.01.034

Cited by 213 publications

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“…Our trial also provides clinical evidence that there is no significant advantage to the administration of a hyperemic agent -a finding consistent with results of studies in which iFR and FFR were compared with other reference standards. 13,14,19,20 Although evidence supporting the benefits of physiologically guided revascularization has accumulated over the past decade, adoption of this approach in clinical practice has lagged. There are many reasons for this, including equipment and drug costs, inadequate reimbursement, physician preferences, patient symptoms, and addi- …”

Section: Discussionmentioning

confidence: 99%

“…11 Several studies have questioned the need for the administration of a vasodilator to assess stenosis severity. [12][13][14] In these studies, investigators found that in determining stenosis severity, FFR was not superior to the instantaneous wave-free ratio (iFR), a pressurederived index of stenosis severity that is not obtained with the administration of a vasodilator. We aimed to determine the efficacy and safety of an iFR-guided strategy versus an FFR-guided strategy for coronary revascularization.…”

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confidence: 99%

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Use of the Instantaneous Wave-free Ratio or Fractional Flow Reserve in PCI

et al. 2017

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BACKGROUNDCoronary revascularization guided by fractional flow reserve (FFR) is associated with better patient outcomes after the procedure than revascularization guided by angiography alone. It is unknown whether the instantaneous wave-free ratio (iFR), an alternative measure that does not require the administration of adenosine, will offer benefits similar to those of FFR. METHODSWe randomly assigned 2492 patients with coronary artery disease, in a 1:1 ratio, to undergo either iFR-guided or FFR-guided coronary revascularization. The primary end point was the 1-year risk of major adverse cardiac events, which were a composite of death from any cause, nonfatal myocardial infarction, or unplanned revascularization. The trial was designed to show the noninferiority of iFR to FFR, with a margin of 3.4 percentage points for the difference in risk. RESULTSAt 1 year, the primary end point had occurred in 78 of 1148 patients (6.8%) in the iFR group and in 83 of 1182 patients (7.0%) in the FFR group (difference in risk, −0.2 percentage points; 95% confidence interval [CI], −2.3 to 1.8; P<0.001 for noninferiority; hazard ratio, 0.95; 95% CI, 0.68 to 1.33; P = 0.78). The risk of each component of the primary end point and of death from cardiovascular or noncardiovascular causes did not differ significantly between the groups. The number of patients who had adverse procedural symptoms and clinical signs was significantly lower in the iFR group than in the FFR group (39 patients [3.1%] vs. 385 patients [30.8%], P<0.001), and the median procedural time was significantly shorter (40.5 minutes vs. 45.0 minutes, P = 0.001). CONCLUSIONSCoronary revascularization guided by iFR was noninferior to revascularization guided by FFR with respect to the risk of major adverse cardiac events at 1 year. The rate of adverse procedural signs and symptoms was lower and the procedural time was shorter with iFR than with FFR. ( Use of Instantaneous Wave-free R atio in PCI F or the past 20 years, physiological measurements obtained during invasive procedures have been used to guide coronary revascularization. Pioneering work supported the use of flow measurements to make safe decisions about revascularization, 1,2 but this approach was soon superseded by the use of fractional flow reserve (FFR), which measures pressure as a surrogate of flow to estimate the severity of stenosis. 3-5 FFR was successful largely because of its technical simplicity and because clinical trials showed that it was associated with improved clinical outcomes after percutaneous coronary intervention (PCI). 6,7 Consequently, FFR is now included in the appropriate-use criteria for coronary angiography and in the American College of Cardiology-American Heart Association-European Society of Cardiology guidelines; despite these recommendations, its adoption remains limited. [8][9][10] FFR must be measured during maximal hyperemia, which is typically induced with the administration of a potent intravenous or intracoronary vasodilator, such as adenosine. 11 Several studies have...

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Use of the Instantaneous Wave-free Ratio or Fractional Flow Reserve in PCI

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“…50 A second, larger study similarly assessed iFR and FFR against HSR in 120 stenoses. In that study, iFR was found to have a significant higher classification match than FFR (89% vs. 82%, P<0.01).…”

Section: Ifr Comparative Studies With Markers Of Ischemiamentioning

confidence: 99%

“…In CLARIFY, both iFR and FFR had equal diagnostic efficiency to match an ischemic classification with HSR (both 92%, with no significant difference between the 2 tests). 50 The CLARIFY study further addressed key questions brought by the cardiology community. One was whether iFR would be lower in the presence of adenosine, and whether the administration of adenosine over the wave-free period with further improve diagnostic categorization.…”

Section: Clarify Study: Assessing the Effect Of Hyperemia On The Wavementioning

confidence: 99%

Advances in Coronary Physiology

Nijjer

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Petraco

et al. 2015

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Pressure-wire technology, most typically fractional flow reserve (FFR), has provided interventional cardiologists with a means of determining the physiological importance of a stenosis during angiography. There has been renewed interest in coronary physiology in the light of guideline recognition, ongoing clinical research and new technologies changing the paradigm of how assessment is performed in the catheter laboratory. We reflect on FFR, with regards the potential effects of changing hemodynamics on FFR and the latest evidence with regards to outcomes. We also review the instantaneous wave-free ratio (iFR), a new pressure-only index, measured at rest, that is under active evaluation in several international randomized controlled trials. We review the accumulated evidence and discuss the important physiological concepts between pressure and flow that underlie the approach to using resting indices. Finally we investigate future developments, including physiological mapping with iFR-Pullback and the potential to predict the hemodynamic effect of stenting. (Circ J 2015; 79: 1172 -1184

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“…[4][5][6][7] The instantaneous wave-free ratio (iFR) is a recently developed physiological index used to assess the severity of stenosis.The iFR is calculated by measuring the resting pressure gradient across a coronary lesion during the portion of diastole when microvascular resistance is low and stable. 8 Benefits of iFR include the ability to obtain an instantaneous lesion assessment without the need to administer a hyperemic agent, such as adenosine.…”

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Instantaneous Wave-free Ratio versus Fractional Flow Reserve to Guide PCI

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BACKGROUNDThe instantaneous wave-free ratio (iFR) is an index used to assess the severity of coronary-artery stenosis. The index has been tested against fractional flow reserve (FFR) in small trials, and the two measures have been found to have similar diagnostic accuracy. However, studies of clinical outcomes associated with the use of iFR are lacking. We aimed to evaluate whether iFR is noninferior to FFR with respect to the rate of subsequent major adverse cardiac events. METHODSWe conducted a multicenter, randomized, controlled, open-label clinical trial using the Swedish Coronary Angiography and Angioplasty Registry for enrollment. A total of 2037 participants with stable angina or an acute coronary syndrome who had an indication for physiologically guided assessment of coronary-artery stenosis were randomly assigned to undergo revascularization guided by either iFR or FFR. The primary end point was the rate of a composite of death from any cause, nonfatal myocardial infarction, or unplanned revascularization within 12 months after the procedure. RESULTSA primary end-point event occurred in 68 of 1012 patients (6.7%) in the iFR group and in 61 of 1007 (6.1%) in the FFR group (difference in event rates, 0.7 percentage points; 95% confidence interval [CI], −1.5 to 2.8; P = 0.007 for noninferiority; hazard ratio, 1.12; 95% CI, 0.79 to 1.58; P = 0.53); the upper limit of the 95% confidence interval for the difference in event rates fell within the prespecified noninferiority margin of 3.2 percentage points. The results were similar among major subgroups. The rates of myocardial infarction, target-lesion revascularization, restenosis, and stent thrombosis did not differ significantly between the two groups. A significantly higher proportion of patients in the FFR group than in the iFR group reported chest discomfort during the procedure. CONCLUSIONSAmong patients with stable angina or an acute coronary syndrome, an iFR-guided revascularization strategy was noninferior to an FFR-guided revascularization strategy with respect to the rate of major adverse cardiac events at 12 months. (Funded by Philips Volcano; iFR SWEDEHEART ClinicalTrials.gov number, NCT02166736.) a bs tr ac t

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Diagnostic Classification of the Instantaneous Wave-Free Ratio Is Equivalent to Fractional Flow Reserve and Is Not Improved With Adenosine Administration

Abstract: iFR and FFR had equivalent agreement with classification of coronary stenosis severity by HSR. Further reduction in resistance by the administration of adenosine did not improve diagnostic categorization, indicating that iFR can be used as an adenosine-free alternative to FFR.

Cited by 213 publications

References 34 publications

Use of the Instantaneous Wave-free Ratio or Fractional Flow Reserve in PCI

Use of the Instantaneous Wave-free Ratio or Fractional Flow Reserve in PCI

Advances in Coronary Physiology

Instantaneous Wave-free Ratio versus Fractional Flow Reserve to Guide PCI

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