Fractional Flow Reserve–Guided Deferred Versus Complete Revascularization in Patients With Diabetes Mellitus

Kennedy, Mark W.; Hermanides, Rik; Kaplan, Elina; Hemradj, Veemal; Fabris, Enrico; Koopmans, Petra C.; Dambrink, Jan‐Henk E.; Gosselink, A T Marcel; Hof, Arnoud W.J. van’t; Ottervanger, Jan Paul; Roolvink, Vincent; Remkes, Wouter; Sluis, Aize van der; Suryapranata, Harry; Kedhi, Elvin

doi:10.1016/j.amjcard.2016.07.059

Cited by 18 publications

(14 citation statements)

References 23 publications

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“…Conversely, those patients with a high FFR and normal microvascular function (high CFR, low IMR) had excellent outcomes. Thus, based upon this study, abnormal microvascular function may in part explain the worse outcomes in DM patients despite the absence of FFR detected ischemia, as has been recently described in several studies [35–37]. Whether the addition of complementary hemodynamic assessments in DM patients with negative FFR assessments, may result in a more accurate deferred revascularization needs to be studied in larger dedicated studies and the development of repeatable methods of absolute coronary flow measurement may finally help to provide a better understanding of coronary microcirculation [49].…”

Section: Microvascular Disease and Dmsupporting

confidence: 71%

“…Our group have recently shown that compared to those DM patients who undergo complete revascularization, DM patients with ≥1 remaining FFR negative (>0.80) lesion, have a significantly higher incidence of MACE, a composite of death/MI, rehospitalization for acute coronary syndrome (ACS) and TLR, HR 2.01 (95% CI 1.21–3.33, p < 0.01) [35]. Furthermore, significant clustering of MACE events in those DM patients with a previous MI carrying FFR negative lesions was noted, whereas those patients without a previous MI had much more benign outcomes (Fig.…”

Section: Ffr and Diabetes Mellitusmentioning

confidence: 99%

“…1Time-to-event estimates for MACE, in FFR(−)MT and FFR(+)CR groups according to presence or absence of prior MI. MACE major adverse cardiac event; MI myocardial infarction; FFR fractional flow reserve; FFR (−) MT the group of patients with ≥1 FFR negative (FFR > 0.80) lesion(s) which underwent medical therapy; FFR (+) CR the group of patients with all lesions FFR positive (FFR ≤ 0.80) and had complete revascularization; HR adjusted hazard ratio(Reproduced with permission from Kennedy et al [35])

Fig. 2Time-to-event estimates for target lesion failure according to FFR(−)DM and FFR(−)NonDM groups.…”

Section: Ffr and Diabetes Mellitusmentioning

confidence: 99%

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Is ischemia the only factor predicting cardiovascular outcomes in all diabetes mellitus patients?

Kennedy

Fabris

Suryapranata

et al. 2017

Cardiovasc Diabetol

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Diabetes mellitus (DM) is associated with an excess in cardiovascular morbidity and mortality, and is characterized by increased rates of coronary artery disease. Furthermore, once atherosclerosis is established, this is associated with an increased extent, complexity and a more rapid progression than seen in non-DM patients. Ischemia is the single most important predictor of future hard cardiac events and ischemia correction remains the cornerstone of current revascularization strategies. However recent data suggests that, in DM patients, coronary atherosclerosis despite the absence of ischemia, detected by either invasive or non-invasive methods, may not be associated with the same low risk of future cardiac events as seen in non-DM patients. This review seeks to examine the current evidence supporting an ischemia driven revascularization strategy, and to challenge the notion that ischemia is the only clinically relevant factor in the prediction of cardiovascular outcomes in all-comer DM patients. Specifically, we examine whether in DM patients certain characteristics beyond ischemia, such as microvascular disease, coronary atherosclerosis burden, progression and plaque composition, may need to be considered for a more refined risk stratification in these high-risk patients.

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Section: Microvascular Disease and Dmsupporting

confidence: 71%

Section: Ffr and Diabetes Mellitusmentioning

confidence: 99%

Fig. 2Time-to-event estimates for target lesion failure according to FFR(−)DM and FFR(−)NonDM groups.…”

Section: Ffr and Diabetes Mellitusmentioning

confidence: 99%

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Is ischemia the only factor predicting cardiovascular outcomes in all diabetes mellitus patients?

Kennedy

Fabris

Suryapranata

et al. 2017

Cardiovasc Diabetol

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“…Whilst fractional flow reserve (FFR) has an extensive evidence base, a low proportion of patients with DM were included in the landmark studies . Recent evidence has suggested that deferred revascularization based upon FFR in DM patients may not be associated with a similar low risk of MI or target lesion revascularization as seen in non‐DM patients . Whilst risk prediction models have been developed to better predict the risk of FFR‐guided deferred lesion failure (DLF), such models may not be as applicable in DM patients, given the significantly different nature of atherosclerosis seen in this condition .…”

Section: Introductionmentioning

confidence: 99%

Factors associated with deferred lesion failure following fractional flow reserve assessment in patients with diabetes mellitus

Kennedy

Fabris

Hermanides

et al. 2017

Cathet Cardio Intervent

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“…Therefore it cannot be excluded that the accuracy of FFR, and thus also of cFFR, may be affected in case of microvascular disease as occurs in patients with diabetes. Indeed, a recent study has showed that in patients with diabetes, particularly those with previous MI, FFR-based deferred revascularization was associated with poor medium-term outcomes suggesting that the combining of FFR with imaging techniques may be useful to guide our treatment strategy in these patients with high-risk, fast-progressing disease [28]. Comparing FFR-guided deferred revascularization in patients with and without diabetes, Kennedy et al also showed that those with diabetes were associated with a significantly higher rate of target lesion failure [29].…”

Section: Discussionmentioning

confidence: 99%

Diabetes does not impact the diagnostic performance of contrast-based fractional flow reserve: insights from the CONTRAST study

Gargiulo

Stabile

Ferrone

et al. 2017

Cardiovasc Diabetol

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BackgroundAdenosine-free coronary pressure wire metrics have been proposed to test the functional significance of coronary artery lesions, but it is unexplored whether their diagnostic performance might be altered in patients with diabetes.MethodsWe performed a post-hoc analysis of the CONTRAST study, which prospectively enrolled an international cohort of patients undergoing routine fractional flow reserve (FFR) assessment for standard indications. Paired, repeated measurements of all physiology metrics (Pd/Pa, iFR, contrast-based FFR, and FFR) were made. A central core laboratory analyzed blinded pressure tracings in a standardized fashion.ResultsOf 763 subjects enrolled at 12 international centers, 219 (29%) had diabetes. The two groups were well-balanced for age, clinical presentation (stable or unstable), coronary vessel studied, volume and type of intracoronary contrast, and volume of intracoronary adenosine. A binary threshold of cFFR ≤ 0.83 produced an accuracy superior to both Pd/Pa and iFR when compared with FFR ≤ 0.80 in the absence of significant interaction with diabetes status; indeed, accuracy in subgroups of patients with or without diabetes was similar for cFFR (86.7 vs 85.4% respectively; p = 0.76), iFR (84.2 vs 80.0%, p = 0.29) and Pd/Pa (81.3 vs 78.9%, p = 0.55). There was no significant heterogeneity between patients with or without diabetes in terms of sensitivity and specificity of all metrics. The area under the receiver operating characteristic (ROC) curve was largest for cFFR compared with Pd/Pa and iFR which were equivalent (cFFR 0.961 and 0.928; Pd/Pa 0.916 and 0.870; iFR 0.911 and 0.861 in diabetic and non-diabetic patients respectively).ConclusionscFFR provides superior diagnostic performance compared with Pd/Pa or iFR for predicting FFR irrespective of diabetes (clinicaltrials.gov identifier NCT02184117).

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Fractional Flow Reserve–Guided Deferred Versus Complete Revascularization in Patients With Diabetes Mellitus

Cited by 18 publications

References 23 publications

Is ischemia the only factor predicting cardiovascular outcomes in all diabetes mellitus patients?

Is ischemia the only factor predicting cardiovascular outcomes in all diabetes mellitus patients?

Factors associated with deferred lesion failure following fractional flow reserve assessment in patients with diabetes mellitus

Diabetes does not impact the diagnostic performance of contrast-based fractional flow reserve: insights from the CONTRAST study

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