Prognostic Implications of Fractional Flow Reserve After Coronary Stenting

Abstract

ImportanceFractional flow reserve (FFR) after percutaneous coronary intervention (PCI) is generally considered to reflect residual disease. Yet the clinical relevance of post-PCI FFR after drug-eluting stent (DES) implantation remains unclear.ObjectiveTo evaluate the clinical relevance of post-PCI FFR measurement after DES implantation.Data SourcesMEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched for relevant published articles from inception to June 18, 2022.Study SelectionPublished articles that reported post-PCI FFR after DES implantation and its association with clinical outcomes were included.Data Extraction and SynthesisPatient-level data were collected from the corresponding authors of 17 cohorts using a standardized spreadsheet. Meta-estimates for primary and secondary outcomes were analyzed per patient and using mixed-effects Cox proportional hazard regression with registry identifiers included as a random effect. All processes followed the Preferred Reporting Items for Systematic Review and Meta-analysis of Individual Participant Data.Main Outcomes and MeasuresThe primary outcome was target vessel failure (TVF) at 2 years, a composite of cardiac death, target vessel myocardial infarction (TVMI), and target vessel revascularization (TVR). The secondary outcome was a composite of cardiac death or TVMI at 2 years.ResultsOf 2268 articles identified, 29 studies met selection criteria. Of these, 28 articles from 17 cohorts provided data, including a total of 5277 patients with 5869 vessels who underwent FFR measurement after DES implantation. Mean (SD) age was 64.4 (10.1) years and 4141 patients (78.5%) were men. Median (IQR) post-PCI FFR was 0.89 (0.84-0.94) and 690 vessels (11.8%) had a post-PCI FFR of 0.80 or below. The cumulative incidence of TVF was 340 patients (7.2%), with cardiac death or TVMI occurring in 111 patients (2.4%) at 2 years. Lower post-PCI FFR significantly increased the risk of TVF (adjusted hazard ratio [HR] per 0.01 FFR decrease, 1.04; 95% CI, 1.02-1.05; P < .001). The risk of cardiac death or MI also increased inversely with post-PCI FFR (adjusted HR, 1.03; 95% CI, 1.00-1.07, P = .049). These associations were consistent regardless of age, sex, the presence of hypertension or diabetes, and clinical diagnosis.Conclusions and RelevanceReduced FFR after DES implantation was common and associated with the risks of TVF and of cardiac death or TVMI. These results indicate the prognostic value of post-PCI physiologic assessment after DES implantation.

Physiology- or Imaging-Guided Strategies for Intermediate Coronary Stenosis

“…Although clinical outcomes between IVUS and FFR groups were not significantly different according to the prespecified optimization criteria in this study, high-risk revascularized vessels can be defined using the optimal cutoff of post-PCI FFR, MSA, and plaque burden at stent edge, which were associated with a higher risk of TVF than low-risk revascularized vessels. This finding aligns with prior publications that reported the prognostic value of residual ischemia, or IVUS-defined post-PCI plaque burden or stent underexpansion . It should be noted that there was no statistically significant association of continuous FFR and IVUS parameters with TVF did in this study.…”

“…While intravascular imaging is recommended for planning and optimization of PCI, poststent physiological assessment can also independently estimate risk of adverse clinical events after stent implantation . Nonetheless, head-to-head comparison of clinical outcomes between physiology- and imaging-based PCI optimization has rarely been conducted.…”

Predictive Value of Post-Percutaneous Coronary Intervention Quantitative Flow Ratio for Vessel-Oriented Composite Endpoint

“…In addition, it was found that FFR values measured after PCI could predict the long-term outcome of patients [25]. Systematic reviews and metaanalysis had also reached similar conclusions [10,26]. In recent years, studies had shown that QFR could also predict post-PCI VOCE [1,[12][13][14][15][16].…”

“…Tis method should be feasible. Tis is also the case with other metaanalysis, such as the meta-analysis published by Hwang [26] in JAMA in 2022. Hence, the results of this study should be considered exploratory.…”

Clinical Outcomes of Deferred Lesions by IVUS Versus FFR-Guided Treatment Decision

“…23 This is based on the fact that not all PCIs were necessarily physiologically optimized, despite physiology-guided and angiographically successful PCI, and that clinical outcomes differed significantly according to post-PCI physiological optimization. 24 Meanwhile, there has been an attempt to use IVUS as a treatment decision-making tool. In a previous study by Nam et al, IVUS-guided treatment decision-making resulted in higher rates of revascularization than FFR-guided treatment decision-making in 167 patients with intermediate coronary artery stenosis; however, there was no significant difference in major adverse cardiac event rates between the 2 groups at 1 year.…”