Revascularization Decisions in Patients With Stable Angina and Intermediate Lesions

Tóth, Gábor G.; Toth, Balint; Johnson, Nils P.; Vroey, Frederic De; Serafino, Luigi Di; Pyxaras, Stylianos A.; Ruşinaru, Dan; Gioia, Giuseppe Di; Pellicano, Mariano; Barbato, Emanuele; Mieghem, Carlos Van; Heyndrickx, Guy R.; Bruyne, Bernard De; Wijns, William

doi:10.1161/circinterventions.114.001608

Cited by 146 publications

(85 citation statements)

References 26 publications

(24 reference statements)

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“…In this regard, future study evaluating the prognostic impact of CR is warranted to use the concept of functionally complete revascularization. Nevertheless, angiographic completeness of coronary revascularization might also carry a certain clinical importance, considering the limited adoption rates of invasive physiologic assessment globally 37. Fourth, as the current study mainly focused on the comparison of clinical outcomes between angiographic CR and IR groups, the lack of an appropriate comparator, such as medical treatment or coronary artery bypass grafting, makes inferences incomplete.…”

Section: Discussionmentioning

confidence: 97%

Differential Clinical Outcomes Between Angiographic Complete Versus Incomplete Coronary Revascularization, According to the Presence of Chronic Kidney Disease in the Drug‐Eluting Stent Era

Kim

Lee

Choi

et al. 2018

JAHA

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BackgroundThere are limited data regarding the prognostic impact of angiographic complete revascularization (CR) in patients with chronic kidney disease (CKD). We sought to investigate the differential prognostic impact of angiographic CR over incomplete revascularization (IR), according to the presence of CKD in the drug‐eluting stent era.Methods and ResultsBetween 2003 and 2011 at Samsung Medical Center, consecutive patients with multivessel disease were stratified by the presence of CKD (estimated glomerular filtration rate <60 mL/min per 1.73 m2) and classified according to angiographic CR (residual SYNTAX score=0) or IR. Clinical outcomes were compared between angiographic CR and IR, stratified by the presence of CKD. Primary outcome was patient‐oriented composite outcomes (POCO, a composite of all‐cause death, myocardial infarction, any revascularization) at 3 years. Inverse probability weighting was performed between the CR and IR groups. A total of 3224 patients were eligible for analysis: 2295 without CKD; 929 with CKD. Among non‐CKD patients, angiographic CR showed a significantly lower risk of POCO than IR (17.2% versus 21.7%, adjusted hazard ratio 0.76, 95% confidence interval, 0.62–0.95, P=0.014), mainly driven by a significantly lower risk of any revascularization. Among CKD patients, however, angiographic CR was associated with a significantly higher risk of POCO than IR (37.7% versus 28.4%, adjusted hazard ratio 1.42, 95% confidence interval, 1.08%–1.85%, P=0.011), mainly driven by a significantly higher risk of nonfatal target vessel myocardial infarction.ConclusionsAngiographic CR was associated with reduced risk of POCO than IR in patients without CKD; however, it was associated with a significantly higher risk of POCO and nonfatal myocardial infarction in CKD patients.

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Section: Discussionmentioning

confidence: 97%

Differential Clinical Outcomes Between Angiographic Complete Versus Incomplete Coronary Revascularization, According to the Presence of Chronic Kidney Disease in the Drug‐Eluting Stent Era

Kim

Lee

Choi

et al. 2018

JAHA

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“…Following the FAME (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation [fractional flow reserve versus angiography for guiding percutaneous coronary intervention]) trials, the adoption of fractional flow reserve (FFR) has improved with a 16‐fold increase in FFR‐guided percutaneous coronary intervention in the United States from 2008 to 2012 1. Globally, the use of physiological lesion assessment remains low, with large areas performing less than 15% of eligible procedures with physiology guidance 2, 3…”

Section: Introductionmentioning

confidence: 99%

Diagnostic Performance of In‐Procedure Angiography‐Derived Quantitative Flow Reserve Compared to Pressure‐Derived Fractional Flow Reserve: The FAVOR II Europe‐Japan Study

Westra

Andersen

Campo

et al. 2018

JAHA

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296

305

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BackgroundQuantitative flow ratio (QFR) is a novel modality for physiological lesion assessment based on 3‐dimensional vessel reconstructions and contrast flow velocity estimates. We evaluated the value of online QFR during routine invasive coronary angiography for procedural feasibility, diagnostic performance, and agreement with pressure‐wire–derived fractional flow reserve (FFR) as a gold standard in an international multicenter study.Methods and Results FAVOR II E‐J (Functional Assessment by Various Flow Reconstructions II Europe‐Japan) was a prospective, observational, investigator‐initiated study. Patients with stable angina pectoris were enrolled in 11 international centers. FFR and online QFR computation were performed in all eligible lesions. An independent core lab performed 2‐dimensional quantitative coronary angiography (2D‐QCA) analysis of all lesions assessed with QFR and FFR. The primary comparison was sensitivity and specificity of QFR compared with 2D‐QCA using FFR as a reference standard. A total of 329 patients were enrolled. Paired assessment of FFR, QFR, and 2D‐QCA was available for 317 lesions. Mean FFR, QFR, and percent diameter stenosis were 0.83±0.09, 0.82±10, and 45±10%, respectively. FFR was ≤0.80 in 104 (33%) lesions. Sensitivity and specificity by QFR was significantly higher than by 2D‐QCA (sensitivity, 86.5% (78.4–92.4) versus 44.2% (34.5–54.3); P<0.001; specificity, 86.9% (81.6–91.1) versus 76.5% (70.3–82.0); P=0.002). Area under the receiver curve was significantly higher for QFR compared with 2D‐QCA (area under the receiver curve, 0.92 [0.89–0.96] versus 0.64 [0.57–0.70]; P<0.001). Median time to QFR was significantly lower than median time to FFR (time to QFR, 5.0 minutes [interquartile range, –6.1] versus time to FFR, 7.0 minutes [interquartile range, 5.0–10.0]; P<0.001).ConclusionsOnline computation of QFR in the catheterization laboratory is clinically feasible and is superior to angiographic assessment for evaluation of intermediary coronary artery stenosis using FFR as a reference standard.Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02959814.

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“…Based on numerous randomized trials [2][3][4][5] and registries in most subsets of lesions and patients, the threshold value of 0.80 has been widely accepted to guide clinical decision making. [6][7][8][9][10][11] (Belgium) with an isolated stenosis and an FFR value within the gray zone of 0.76 to 0.80, irrespective of the angiographic severity and lesion location. To serve as controls, we also considered for inclusion patients presenting with an isolated stenosis and an FFR value in the adjacent FFR strata of 0.70 to 0.75 and 0.81 to 0.85.…”

mentioning

confidence: 99%

Significance of Intermediate Values of Fractional Flow Reserve in Patients With Coronary Artery Disease

Adjedj¹,

Bruyne²,

Floré³

et al. 2016

Circulation

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119

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Background— The fractional flow reserve (FFR) value of 0.75 has been validated against ischemic testing, whereas the FFR value of 0.80 has been widely accepted to guide clinical decision making. However, revascularization when FFR is 0.76 to 0.80, within the so-called gray zone, is still debatable. Methods and Results— From February 1997 to June 2013, all patients with single-segment disease and an FFR value within the gray zone or within the 2 neighboring FFR strata (0.70–0.75 and 0.81–0.85) were included. Study end points consisted of major adverse cardiovascular events (death, myocardial infarction, and any revascularization) up to 5 years. Of 17 380 FFR measurements, 1459 patients were included. Of them, 449 patients were treated with revascularization and 1010 patients were treated with medical therapy. In the gray zone, the major adverse cardiovascular events rate was similar (37 [13.9%] versus 21 [11.2%], respectively; P =0.3) between medical therapy and revascularization, whereas a strong trend toward a higher rate of death or myocardial infarction (25 [9.4] versus 9 [4.8], P =0.06) and overall death (20 [7.5] versus 6 [3.2], P =0.059) was observed in the medical therapy group. Among medical therapy patients, a significant step-up increase in major adverse cardiovascular events rate was observed across the 3 FFR strata, especially with proximal lesion location. In revascularization patients, the major adverse cardiovascular events rate was not different across the 3 FFR strata. Conclusions— FFR in and around the gray zone bears a major prognostic value, especially in proximal lesions. These data confirm that FFR≤0.80 is valid to guide clinical decision making.

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Revascularization Decisions in Patients With Stable Angina and Intermediate Lesions

Cited by 146 publications

References 26 publications

Differential Clinical Outcomes Between Angiographic Complete Versus Incomplete Coronary Revascularization, According to the Presence of Chronic Kidney Disease in the Drug‐Eluting Stent Era

Differential Clinical Outcomes Between Angiographic Complete Versus Incomplete Coronary Revascularization, According to the Presence of Chronic Kidney Disease in the Drug‐Eluting Stent Era

Diagnostic Performance of In‐Procedure Angiography‐Derived Quantitative Flow Reserve Compared to Pressure‐Derived Fractional Flow Reserve: The FAVOR II Europe‐Japan Study

Significance of Intermediate Values of Fractional Flow Reserve in Patients With Coronary Artery Disease

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