Five-Year Outcomes with PCI Guided by Fractional Flow Reserve

Xaplanteris, Panagiotis; Fournier, Stéphane; Pijls, Nico H.J.; Fearon, William F.; Barbato, Emanuele; Tonino, Pim A.L.; Engstrøm, Thomas; Kääb, Stefan; Dambrink, J-H E; Rioufol, Gilles; Tóth, Gábor G.; Piróth, Zsolt; Witt, Nils; Fröbert, Ole; Kala, Petr; Linke, Axel; Jagić, Nikola; Mates, Martin; Mavromatis, Kreton; Samady, Habib; Irimpen, Anand; Oldroyd, Keith G.; Campo, Gianluca; Rothenbühler, Martina; Jüni, Peter; Bruyne, Bernard De

doi:10.1056/nejmoa1803538

Cited by 688 publications

(498 citation statements)

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“…[8][9][10][11][12][13][14][15][30][31][32][33][34][35][36] For instance, coronary CTA-based CFD models have been used to compute noninvasive FFR in CAD, allowing a considerable proportion of CAD patients to avoid the invasive FFR procedure, without increasing the risk of major adverse cardiovascular events. [8][9][10][11][12][13][14][15][30][31][32][33][34][35][36] For instance, coronary CTA-based CFD models have been used to compute noninvasive FFR in CAD, allowing a considerable proportion of CAD patients to avoid the invasive FFR procedure, without increasing the risk of major adverse cardiovascular events.…”

Section: Discussionmentioning

confidence: 99%

“…[8][9][10][11] Studies on coronary and carotid artery diseases have also indicated that another hemodynamic index, wall shear stress (WSS), may be involved in evolution of atherosclerotic lesions and the risk of subsequent relevant ischemic events. [8][9][10][11] Studies on coronary and carotid artery diseases have also indicated that another hemodynamic index, wall shear stress (WSS), may be involved in evolution of atherosclerotic lesions and the risk of subsequent relevant ischemic events.…”

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confidence: 99%

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Hemodynamics and stroke risk in intracranial atherosclerotic disease

Leng

Lan

et al. 2019

Annals of Neurology

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Objective: To investigate whether hemodynamic features of symptomatic intracranial atherosclerotic stenosis (sICAS) might correlate with the risk of stroke relapse, using a computational fluid dynamics (CFD) model. Methods: In a cohort study, we recruited patients with acute ischemic stroke attributed to 50 to 99% ICAS confirmed by computed tomographic angiography (CTA). With CTA-based CFD models, translesional pressure ratio (PR = pressure poststenotic /pressure prestenotic ) and translesional wall shear stress ratio (WSSR = WSS stenotic − throat /WSS prestenotic ) were obtained in each sICAS lesion. Translesional PR ≤ median was defined as low PR and WSSR ≥4th quartile as high WSSR. All patients received standard medical treatment. The primary outcome was recurrent ischemic stroke in the same territory (SIT) within 1 year. Results: Overall, 245 patients (median age = 61 years, 63.7% males) were analyzed. Median translesional PR was 0.94 (interquartile range [IQR] = 0.87-0.97); median translesional WSSR was 13.3 (IQR = 7.0-26.7). SIT occurred in 20 (8.2%) patients, mostly with multiple infarcts in the border zone and/or cortical regions. In multivariate Cox regression, low PR (adjusted hazard ratio [HR] = 3.16, p = 0.026) and high WSSR (adjusted HR = 3.05, p = 0.014) were independently associated with SIT. Patients with both low PR and high WSSR had significantly higher risk of SIT than those with normal PR and WSSR (risk = 17.5% vs 3.0%, adjusted HR = 7.52, p = 0.004). Interpretation: This work represents a step forward in utilizing computational flow simulation techniques in studying intracranial atherosclerotic disease. It reveals a hemodynamic pattern of sICAS that is more prone to stroke relapse, and supports hypoperfusion and artery-to-artery embolism as common mechanisms of ischemic stroke in such patients. ANN NEUROL 2019;85:752-764 I ntracranial atherosclerotic stenosis (ICAS) is a major cause of ischemic stroke in Asian populations, contributing to 30 to 50% of ischemic stroke and transient ischemic attack (TIA). 1,2 In earlier pivotal trials on treatment of symptomatic ICAS (sICAS) patients, such as the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial, risk of recurrent stroke and death was up to 15% at 1 year among those with 50 to 99% sICAS treated with aspirin. 3 In the last few years, risk of recurrent stroke in such patients has decreased with better cardiovascular risk factor management, but still higher than stroke patients without ICAS. For instance, among minor stroke or high-risk TIA patients treated with aspirin plus clopidogrel for 21 days followed by clopidogrel mono therapy for days 22 to 90 in the View this article online at wileyonlinelibrary.com.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

Hemodynamics and stroke risk in intracranial atherosclerotic disease

Leng

Lan

et al. 2019

Annals of Neurology

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“…At present, invasive FFR is considered the reference standard for guiding coronary revascularization [19], as it is the only diagnostic test shown to improve clinical outcomes and reduce health costs in large, prospective, randomized trials [20-22]. The use of FFR, however, is limited by its invasive nature and cannot always be measured in all vessels of interest because of extreme vessel tortuosity or coronary calcification [23].…”

Section: Introductionmentioning

confidence: 99%

Functional and Anatomical Testing in Intermediate Risk Chest Pain Patients with a High Coronary Calcium Score: Rationale and Design of the FACC Study

Øvrehus¹,

Veien²,

Lambrechtsen³

et al. 2019

Cardiology

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Current guidelines do not recommend coronary computed tomography angiography (CCTA) in patients with high levels of coronary calcium, as severe calcification leads to difficulties in estimating stenosis severity due to blooming artifacts obscuring the vessel lumen. Whether the CCTA-derived fractional flow reserve (FFR_CT) improves the diagnostic performance of CCTA in patients with high levels of coronary calcification has not been sufficiently evaluated. We hypothesize that a noninvasive diagnostic strategy using FFR_CT will perform comparably to an invasive diagnostic strategy in the detection of hemodynamically significant coronary artery disease (CAD) in clinical stable chest pain patients with high levels of coronary calcium. In this prospective, blinded, multicenter study, patients with suspected stable CAD referred for CCTA and demonstrating an Agatston score >399 will be included. Patients accepting inclusion will, in addition to CCTA, undergo invasive coronary angiography (ICA) and invasive FFR measurement. FFR_CT analyses are performed by an external core laboratory blinded to any patient data, and the FFR_CT results are blinded to all participating study sites. The primary objective is to evaluate whether FFR_CT can identify patients with and without hemodynamically significant CAD, when ICA with FFR is the reference standard. A negative study result would question the clinical usefulness of FFR_CT in patients with high levels of coronary calcium. A positive study result, however, would imply a reduction in the number of patients referred for coronary catheterization and, at the same time, increase the proportion of patients with hemodynamically significant CAD at the subsequent invasive examination.

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“…The FFR‐based deferral of revascularization is reportedly associated with excellent clinical outcomes under optimal medical therapy. Based on the previous studies, the lesions with FFR value >0.80 have been considered to have no need of revascularization . The prevention of future interventions or cardiac events related to such deferred lesions is of extreme importance after deferral of revascularization.…”

Section: Introductionmentioning

confidence: 99%

Impact of intensively lowered low‐density lipoprotein cholesterol on deferred lesion prognosis

Nakamura

Yamamoto

Teng

et al. 2019

Cathet Cardio Intervent

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Objectives The aim of this study was to investigate the impact of intensively lowered low‐density lipoprotein cholesterol (LDL‐C) level on the deferred lesion prognosis after revascularization deferral based on fractional flow reserve (FFR). Background Lowering LDL‐C is associated with lower cardiovascular event rate, but its benefit on the deferred lesion prognosis has not been well evaluated. Methods This retrospective, single‐center, observational study analyzed 192 deferred lesions with FFR value >0.80 in 192 patients with stable coronary artery disease. According to the first follow‐up LDL‐C level, they were assigned to the LOW group (<70 mg/dL) or the HIGH group (≥70 mg/dL). Deferred lesion failure (DLF) was defined as the composite of deferred lesion revascularization and deferred vessel myocardial infarction. Results Of all participants, 61 and 131 patients were assigned to the LOW and the HIGH group, respectively. During the median follow‐up of 2.8 years, DLF occurred in 1 and 14 patients in the LOW group and the HIGH group (1.6% and 10.7%, log‐rank p = .043), respectively. The incidence of any unplanned revascularization was also significantly lower in the LOW group than in the HIGH group (3.3% vs. 14.5%, log‐rank p = .032). Conclusions The incidence of DLF was significantly lower in the patients with LDL‐C < 70 mg/dL than in those with LDL‐C ≥ 70 mg/dL at the first follow‐up after FFR‐based deferral of revascularization.

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Five-Year Outcomes with PCI Guided by Fractional Flow Reserve

Cited by 688 publications

References 20 publications

Hemodynamics and stroke risk in intracranial atherosclerotic disease

Hemodynamics and stroke risk in intracranial atherosclerotic disease

Functional and Anatomical Testing in Intermediate Risk Chest Pain Patients with a High Coronary Calcium Score: Rationale and Design of the FACC Study

Impact of intensively lowered low‐density lipoprotein cholesterol on deferred lesion prognosis

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