Prognostic Value of Quantitative Flow Ratio Based Functional SYNTAX Score in Patients With Left Main or Multivessel Coronary Artery Disease

Abstract

Background: The potential impact of quantitative flow ratio (QFR) based functional Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score (FSS QFR ) on prognostication and revascularization strategy choice has not been fully investigated, and the discriminant ability of FSS QFR needs further validation. Methods: QFR was retrospectively analyzed in left main or patients with multivessel coronary artery disease from the PANDA III trial. A total of 607 patients with analyzable QFR in all vessels were included. FSS QFR was counted by summing the individual scores only in ischemia-producing lesions (vessel QFR ≤0.8). Patients were stratified according to tertiles of SYNTAX score (SS), and 3 groups of FSS were divided by the same cutoff score. The primary end point was 2-year major adverse cardiac events (a composite of cardiac death, any myocardial infarction, or ischemia-driven revascularization). Results: After calculating the FSS QFR , 16% (96/607) of study patients moved from higher-risk group by SS to lower-risk group. In the low, intermediate, and high FSS QFR group, the cumulative incidence of 2-year major adverse cardiac events was 9.1%, 13.5%, and 22.3% ( P =0.0004), and the rate of a composite of cardiac death or myocardial infarction (3.8%, 7.3%, and 13.7%, P= 0.0006) was also increased. Compared with SS, FSS QFR significantly improved risk classification and prognostication (area under the curve of the receiver-operating characteristics 0.65 versus 0.62, P= 0.0009). Moreover, 6% (38/607) of patients, for whom coronary artery bypass grafting would be recommended according to SS, converted to favor percutaneous coronary intervention after FSS QFR calculation. After multivariate adjustment, FSS QFR was an independent predictor of 2-year major adverse cardiac events (adjusted hazard ratio, 1.05 [95% CI, 1.02–1.07]; P =0.0001). Conclusions: Among patients with left main or multivessel coronary artery disease, FSS QFR showed applicability in prognostication and revascularization strategy choice. An improved scoring system combining anatomy and physiology (FSS QFR ) discriminated the risk of adverse events modestly better than anatomic assessment (SS) alone. REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02017275.

Physiologic Lesion Assessment to Optimize Multivessel Disease

“…Several studies have validated the accuracy and high correlation of QFR with FFR as a diagnostic reference [44][45][46]. Furthermore, QFR incorporation into functional SYNTAX score improves the prognostication and revascularization strategy choice compared to anatomic assessment alone in patients with left main or multivessel coronary artery disease [47]. QFR computation may also be a reliable tool to guide revascularization of non-infarct coronary arteries in the acute setting for patients with STEMI [48,49].…”

Integrated coronary disease burden and patterns to discriminate vessels benefiting from percutaneous coronary intervention

“…Coronary angiography was performed using standard techniques. 11 Angiographic views were obtained after administration of intracoronary nitrate (100 or 200 mg). All angiograms were analyzed at a core laboratory (CCRF, Beijing, China) in a blinded fashion.…”

“…QFR measurements were conducted for all eligible patients in PANDA III trial as described before. 11,12 In brief, vessels with lesions of ≥ 50% diameter stenosis and reference luminal diameter ≥ 2.5 mm by visual assessment were identified as vessels in need of QFR measurement. Off-line QFR analysis was performed blindly by well-trained analysts from an independent core laboratory (CCRF, Beijing, China), using QFR system (AngioPlus, Pulse Medical Imaging Technology, Shanghai, China).…”

Quantitative Flow Ratio

“…The FSS QFR can potentially further refine prognostic risk estimation when compared with the classic anatomic SYNTAX score. Additionally, Zhang et al 40) reported that the FSS QFR in patients with left main or multivessel coronary disease was an independent predictor of the 2-year MACE.…”