Does Routine Pressure Wire Assessment Influence Management Strategy at Coronary Angiography for Diagnosis of Chest Pain?

Abstract

Background-The use of coronary angiography (CA) for diagnosis and management of chest pain (CP) has several flaws.The assessment of coronary artery disease using fractional flow reserve (FFR) is a well-validated technique for describing lesion-level ischemia and improves clinical outcome in the context of percutaneous coronary intervention. The impact of routine FFR at the time of diagnostic CA on patient management has not been determined. Methods and Results-Two hundred patients with stable CP underwent CA for clinical indications. The supervising cardiologist (S.C.) made a management plan based on CA (optimal medical therapy alone, percutaneous coronary intervention, coronary artery bypass grafting, or more information required) and also recorded which stenoses were significant. An interventional cardiologist then measured FFR in all patent coronary arteries of stentable diameter (≥2.25 mm). S.C. was then asked to make a second management plan when FFR results were disclosed. Overall, after disclosure of FFR data, management plan based on CA alone was changed in 26% of patients, and the number and localization of functional stenoses changed in 32%. Specifically, of 72 cases in which optimal medical therapy was recommended after CA, 9 (13%) were actually referred for revascularization with FFR data. By contrast, of 89 cases in whom management plan was optimal medical therapy based on FFR, revascularization would have been recommended in 25 (28%) based on CA. Conclusions-Routine measurement of FFR at CA has important influence both on which coronary arteries have significant stenoses and on patient management. These findings could have important implications for clinical practice. Clinical Trial Registration-URL: http://www.clinicaltrial.gov. Unique identifier: NCT01070771.(Circ Cardiovasc Interv. 2014;7:248-255.)

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

“…23 This may be in part because the use of adenosine in the catheterization laboratory has infrequently been associated with complications. [24][25][26] On the basis of the findings observed in our study, iFR, which allows for lesion assessment without the use of adenosine, has the potential to increase the use of physiologically guided assessment among patients with coronary artery disease, the majority of whom still undergo angiographic assessment of lesion severity.…”

Clinical Outcomes of Deferred Lesions With Angiographically Insignificant Stenosis But Low Fractional Flow Reserve

“…study evaluated the clinical implications of routine FFR measurement in all coronary arteries and demonstrated an important influence on planning patient management 23. In the RIPCORD study, ≈16% of lesions with percentage of diameter stenosis (%DS) <50% showed FFR <0.80.…”

Routine Pressure Wire Assessment at Time of Diagnostic Angiography

“…reclassification of individual management in a large proportion of patients: 26% in RIPCORD 5 and 47% in R3F. Second, reclassification of the treatment strategy was achieved in all groups of treatment.…”

“…Despite this evidence, the role of FFR in patients referred for a diagnostic angiography, although of potential critical importance for patient management, was unknown before the publication of the RIPCORD 5 and R3F studies. 6 The RIPCORD 5 study was conducted in 10 centers in the United Kingdom and included 200 patients referred for a coronary angiography.…”

“…The impact of FFR on patient management was investigated by comparing the 2 therapeutic proposals. Beside the number of patients included, the main design differences between the 2 studies were the following: (1) In RIPCORD, 5 no post-acute coronary syndrome patients were included although they represented 20% of the R3F population 6 ; (2) In RIPCORD, 5 all patients with ≥1 lesion >30% without any upper limit could be included, whereas in the R3F, patients with ≥1 ambiguous lesion (30%-65%) were included; (3) In RIPCORD, 5 the investigators were asked to perform FFR assessment in all major coronary vessels, whereas no specific recommendations were provided to the R3F investigators, leading to a higher number of lesions investigated in each patient in RIPCORD than in R3F (2.9 versus 1.4) 5,6 ; (4) In RIPCORD, 5 the additional fluoroscopy time and extra contrast media related to the FFR assessment were recorded, which was not the case in R3F; (5) Although no long-term follow-up was available in RIPCORD, 5 a 1-year clinical follow-up was part of R3F; (6) The number of patients included in R3F allowed for a multivariable analysis of the predictors of the FFR value and of the changes of the therapeutical plan.…”