Impact of Routine Fractional Flow Reserve Evaluation During Coronary Angiography on Management Strategy and Clinical Outcome

Abstract

Background-Penetration of fractional flow reserve (FFR) in clinical practice varies extensively, and the applicability of results from randomized trials is understudied. We describe the extent to which the information gained from routine FFR affects patient management strategy and clinical outcome. Methods and Results-Nonselected patients undergoing coronary angiography, in which at least 1 lesion was interrogated by FFR, were prospectively enrolled in a multicenter registry. FFR-driven change in management strategy (medical therapy, revascularization, or additional stress imaging) was assessed per-lesion and per-patient, and the agreement between final and initial strategies was recorded. Cardiovascular death, myocardial infarction, or unplanned revascularization (MACE) at 1 year was recorded. A total of 1293 lesions were evaluated in 918 patients (mean FFR, 0.81±0.1). Management plan changed in 406 patients (44.2%) and 584 lesions (45.2%). One-year MACE was 6.9%; patients in whom all lesions were deferred had a lower MACE rate (5.3%) than those with at least 1 lesion revascularized (7.3%) or left untreated despite FFR≤0.80 (13.6%; log-rank P=0.014). At the lesion level, deferral of those with an FFR≤0.80 was associated with a 3.1-fold increase in the hazard of cardiovascular death/myocardial infarction/target lesion revascularization (P=0.012). Independent predictors of target lesion revascularization in the deferred lesions were proximal location of the lesion, B2/C type and FFR. Conclusions-Routine FFR assessment of coronary lesions safely changes management strategy in almost half of the cases. Also, it accurately identifies patients and lesions with a low likelihood of events, in which revascularization can be safely deferred, as opposed to those at high risk when ischemic lesions are left untreated, thus confirming results from randomized trials. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01835808. Results from the FAME 2 (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation 2) study suggested that deferring the revascularization of epicardial stenosis with an FFR≤0.80 was associated with an 11.4% absolute increase in the risk of major cardiovascular events at 24 months (8.1% in revascularized patients versus 19.5% in medically treated), an hazard that was mainly driven by urgent revascularization. 4In spite of the overwhelming evidence of its potential clinical and economic benefits 5 and strong guideline recommendation, 6 the adoption of FFR in the real-world is perceived to vary significantly. Reasons for this disparity are several, but most operators still do rely the most on angiographic eyeballing to decide on the functional significance of coronary lesions and the need for revascularization. 7The Portuguese Study on the Evaluation of FFR-Guided Treatment of Coronary Disease (POST-IT) was a prospective registry designed to describe the patterns of the use of FFR in an unselected real-world population, to assess its impact on clinical decis...

Fractional Flow Reserve (FFR) guided Percutaneous Coronary Intervention (PCI) to Avoid Inappropriate Stenting in Patient with Angiographically Significant Stenotic Coronary Artery Lesion–Our Experiences at Apollo Hospitals Dhaka

“…Thus, the FFR guided treatment could have been more economical in daily practice if decision making for PCI relies more strictly on FFR value. 22 Baptista et al 23 demonstrated that routine assessment of coronary lesions by FFR, safely changes patient management strategy in half of the patients with a low likelihood of events in deferred revascularization. In addition, our present study is very much consistent with Baptista et al, where we deferred PCI in more than 50% of patient based on FFR value <0.75 and waiting to observe an events in future if any.…”

Funktionelle Diagnostik zur Detektion myokardialer Ischämie

“…Eine PCI sollte bei pathologischer FFR erfolgen und bei einer FFR ≥ 0,80 nicht durchgeführt werdendies gilt aufgrund der prognostischen Bedeutung auch für asymptomatische Patienten [1]. Dieses Vorgehen führt häufig zu einer Veränderung der Therapieregimes [25].…”

Routine Fractional Flow Reserve Combined to Diagnostic Coronary Angiography as a One-Stop Procedure

“…The POST-IT (Portuguese Study on the Evaluation of FFR Guided Treatment of Coronary Disease) study 7 including ≈1000 patients and published in this issue of Circulation: Cardiovascular Interventions provides additional fuel to this emerging concept. Altogether, R3F, RIPCORD, and POST-IT are combining >2000 patients while sharing a similar prospective design to investigate the role of routine FFR at time of angiography on the therapeutic decision process.…”

“…A key addition of the POST-IT study 7 is the demonstration that the implementation of routine FFR during angiography as the potential to reduce drastically the use of noninvasive tests. In this study, physicians requested the performance of a noninvasive test to clarify the patient management after coronary angiography in 22% of cases.…”

“…Another key contribution of the POST-IT study 7 is to help to elucidate an important misconception about FFR. Since the results of the DEFER study, 8 demonstrating that performing FFR in patients referred for PCI prevents the need of angioplasty in about 50% of them, most of the interventionalists think that an extensive use of this technology will unequivocally lead to a drastic reduction in the number of PCI performed.…”