Abstract 3334: Comparison of Medical Treatment and Coronary Revascularization in Patients with Moderate Coronary Lesions and Borderline Fractional Flow Reserve Measurements

Background. There is little information available regarding deferral of revascularization in cases of fractional flow reserve (FFR) measurements in the borderline range (between 0.75 to 0.80). The objectives of this study were to evaluate the clinical outcomes of patients with moderate coronary lesions and FFR measurements between 0.75 and 0.80, comparing those who underwent coronary revascularization (CR) to those who had medical treatment (MT), and to determine the predictive factors of major adverse cardiac events (MACE) at follow-up. Methods. A total of 107 consecutive patients (mean age 62 ± 10 years) with at least one moderate coronary lesion (mean percent diameter stenosis 47 ± 12%) evaluated by coronary pressure wire with FFR measurement between 0.75 and 0.80 (mean 0.77 ± 0.02) were included in the study. Maximal hyperemia was obtained by intracoronary administration of adenosine (mean dose 215 ± 84 μg). MACE (coronary revascularization, myocardial infarction, cardiac death) and the presence of angina were evaluated at follow-up. Results. A total of 63 patients (59%) underwent CR and 44 patients (41%) had MT, with no clinical differences between groups. At a mean follow-up of 13 ± 7 months, MACE related to the coronary lesion evaluated by FFR were higher in the MT group compared to CR group (23% vs 5%, difference 18%, 95% CI 5%–30%, p=0.005). FFR measurement in an artery supplying a territory with previous myocardial infarction was the only predictive factor of MACE in the MT group (odds ratio 14.1, 95% CI 1.3–39, p=0.03). The presence of angina at follow-up was more frequent in the MT group compared to the CR group (41% vs 9%, difference 32%, 95% CI 11%–49%, p<0.001). Conclusions. In patients with moderate coronary lesions and FFR measurements in the “grey zone” range deferral of revascularization was associated with a higher rate of cardiac events and a higher prevalence of angina at follow-up, especially in those with previous myocardial infarction in the territory evaluated by FFR. These results suggest that a FFR cut-off point of 0.80 rather than 0.75 might be more appropriate for deferring coronary revascularization in these cases.

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Abstract 911: Usefulness of Coronary Fractional Flow Reserve Measurements to Guide Clinical Decisions in Intermediate Left Main Coronary Stenoses. Results of a Study Including 142 Consecutive Patients

Circulation ◽

10.1161/circ.118.suppl_18.s_631 ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Josep Rodès-Cabau ◽

Javier Courtis ◽

Jean-Michel Potvin ◽

Melanie Côté ◽

Jean-Pierre Dery ◽

...

Keyword(s):

Myocardial Infarction ◽

Medical Treatment ◽

Cardiac Death ◽

Coronary Revascularization ◽

Clinical Decisions ◽

Left Main ◽

Cardiac Events ◽

Fractional Flow ◽

Flow Reserve

Background: Limited data exist on the use of fractional flow reserve (FFR) measurements to guide clinical decisions in patients with intermediate left main coronary artery (LMCA) stenosis. Objectives: To evaluate the usefulness of FFR measurements to guide the clinical decision in patients with intermediate LMCA stenosis and to determine the predictors of major adverse cardiac events [MACE] (cardiac death, myocardial infarction, coronary revascularization) in such cases. Methods: A total of 142 consecutive patients (mean age 62 ± 10 yrs) with intermediate LMCA stenosis (mean percent diameter stenosis 42 ± 13%) were included. All patients underwent FFR measurement after intracoronary (ic) administration of adenosine at a dose ≥30 μg. Special care was taken in cases with ostial lesions to pull the catheter out of the LMCA after adenosine administration. The clinical decisions were based on FFR as follows: coronary revascularization was recommended if FFR was <0.75, medical treatment if FFR was >0.80, and individualized decision based on additional clinical data if FFR was between 0.75 and 0.80. The occurrence of MACE was evaluated at 14 ± 11 months follow-up. Results: Mean FFR was 0.81 ± 0.09 after the administration of a mean dose of 176 ± 99 μg of ic adenosine. Based on FFR results, sixty patients (42%) underwent coronary revascularization and 82 patients (58%) received medical treatment. At follow-up, the incidence of MACE related to the LMCA stenosis was 13% in the medical treatment group and 7% in the coronary revascularization group (p=0.27). The incidence of cardiac death and myocardial infarction was 7% in both groups (p=1.0). In the medical treatment group, patients with MACE had received a lower dose of ic adenosine (86 ± 57 μg vs. 167 ± 102 μg, OR: 1.39 for each decrease of 30 μg of ic adenosine, 95% CI 1.02–1.89, p=0.04) and were more frequently diabetics (55% vs. 21%, OR: 4.40, 95% CI 1.17–16.42, p=0.02). Conclusions: FFR measurement is helpful in guiding the decision as to whether to revascularize patients with intermediate LMCA stenosis. However, diabetic patients remain at higher risk, and higher doses than previously recommended of ic adenosine should be used in the evaluation of LMCA to avoid cardiac events due to underestimation of stenosis severity.

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Comparison of medical treatment and coronary revascularization in patients with moderate coronary lesions and borderline fractional flow reserve measurements

Catheterization and Cardiovascular Interventions ◽

10.1002/ccd.21406 ◽

2008 ◽

Vol 71 (4) ◽

pp. 541-548 ◽

Cited By ~ 43

Author(s):

Javier Courtis ◽

Josep Rodés-Cabau ◽

Eric Larose ◽

Jean-Pierre Déry ◽

Can Manh Nguyen ◽

...

Keyword(s):

Medical Treatment ◽

Fractional Flow Reserve ◽

Coronary Revascularization ◽

Fractional Flow ◽

Flow Reserve ◽

Coronary Lesions

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TCT-420: Very Long-term Clinical Follow-up After Fractional Flow Reserve-Guided Coronary Revascularization

Journal of the American College of Cardiology ◽

10.1016/j.jacc.2010.08.490 ◽

2010 ◽

Vol 56 (13) ◽

pp. B96

Keyword(s):

Fractional Flow Reserve ◽

Coronary Revascularization ◽

Fractional Flow ◽

Flow Reserve

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P1251Percutaneous coronary intervention versus medical therapy for coronary lesions with positive fractional flow reserve (FFR) but preserved coronary flow reserve (CFR). A substudy of the COMPARE-ACUTE

European Heart Journal ◽

10.1093/eurheartj/ehz748.0209 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

J D Haeck ◽

F M Zimmermann ◽

M Van 'T Veer ◽

F J Neumann ◽

A S Triantafyllis ◽

...

Keyword(s):

Myocardial Infarction ◽

Clinical Outcomes ◽

Medical Therapy ◽

Fractional Flow Reserve ◽

Coronary Flow ◽

Coronary Intervention ◽

Pressure Gradients ◽

Fractional Flow ◽

Flow Reserve ◽

Coronary Lesions

Abstract Introduction International guidelines recommend performing percutaneous coronary intervention (PCI) on stable coronary lesions with a positive fractional flow reserve (FFR) to improve clinical outcomes. It remains unclear if FFR positive lesions with preserved coronary flow reserved (CFR) might be better treated medically. Purpose This study compared clinical outcomes between PCI and medical therapy for stable FFR-positive lesions with preserved CFR. Methods We performed a substudy of the randomized, multicenter COMPARE-ACUTE trial in which treated ST-elevation myocardial infarction patients with stable non-culprit lesions were randomized to either FFR-guided PCI or medical therapy. Based on baseline and hyperaemic pressure gradients, we computed the so-called pressure bounded-CFR (pb-CFR) and classified lesions as low (<2) or preserved (≥2). Our primary end point was a composite of death from any cause, non-fatal myocardial infarction, revascularization, or cerebrovascular events (MACCE) at 12 months. Results A total of 980 lesions from 885 subjects were included in this sub-study due to availability of baseline and hyperaemic pressure gradients. For the 462 lesions with FFR≤0.80, 249 had a pb-CFR<2 while 29 had a preserved CFR (pb-CFR≥2). The rate of MACCE at 1 year did not differ significantly between subjects with FFR≤0.80 and pb-CFR<2 versus FFR≤0.80 and pb-CFR≥2 (24% vs. 30%, p=0.44). Because of randomization, baseline characteristics were well balanced between subjects with FFR≤0.80 and pb-CFR≥2 who were treated by PCI or medical therapy. Importantly for subjects with FFR≤0.80 and pb-CFR≥2, MACCE occurred more frequently when treated medically compared with PCI (50% vs. 0% respectively, p=0.01). Conclusions In this post-hoc substudy from a large randomized controlled trial of 885 subjects with 980 lesions, a preserved pb-CFR≥2 did not associate with an improved clinical outcome when FFR≤0.80. Subjects with FFR-positive coronary lesions but a preserved pb-CFR experienced significantly worse clinical outcomes when treated medically instead of with PCI. These data suggest that a stenosis with a FFR≤0.80, even when pb-CFR remains preserved, benefits from treatment with PCI. Acknowledgement/Funding Maasstad Cardiovascular Research, Abbott Vascular and St. Jude Medical

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Abstract 14304: Assessing the Association of Adherence to Fractional Flow Reserve Treatment Thresholds and Outcomes of Patients With Coronary Artery Disease

Circulation ◽

10.1161/circ.142.suppl_3.14304 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Maneesh Sud ◽

Lu Han ◽

Maria Koh ◽

Peter Austin ◽

Michael E Farkouh ◽

...

Keyword(s):

Medical Therapy ◽

Fractional Flow Reserve ◽

Coronary Intervention ◽

Routine Practice ◽

Cardiac Events ◽

Fractional Flow ◽

St Segment Elevation ◽

Single Vessel ◽

Flow Reserve

Background: Although fractional flow reserve (FFR) thresholds have been established to guide the use of percutaneous coronary intervention (PCI) or medical therapy, little is known about the adherence to FFR thresholds for PCI in clinical practice and their association with clinical outcomes. Methods: Adults undergoing FFR assessment in a single vessel (excluding ST-segment elevation myocardial infarction [MI]) from April 1, 2013 to March 31, 2018 in Ontario, Canada were included. Patients were divided into two cohorts based on FFR ≤ 0.80 (ischemic) and > 0.80 (non-ischemic). Inverse probability of treatment weighting was used to balance confounders between patients treated with PCI vs. no PCI in each cohort. The primary outcome was major adverse cardiac events (MACE) defined by death, MI, unstable angina, or urgent revascularization. Results: We identified 9,106 patients who underwent single-vessel FFR measurement. Among the 2,693 patients with an ischemic FFR (mean age 65, 27.0% female), 75.3% of patients received PCI and 24.7% were treated only with medical therapy. Over a median follow-up of 2.6 years in the ischemic cohort, PCI was associated with a 20% lower rate of MACE compared to no PCI (24.0% vs. 31.6%; hazard ratio [HR]: 0.80, 95% CI: 0.66-0.96). However, among 6,413 patients with a non-ischemic FFR (mean age 66, 38.9% female), 12.6% received PCI and 87.4% were treated only with medical therapy. Over a median follow-up of 2.8 years in the non-ischemic cohort, PCI was associated with a 42% higher rate of MACE compared to no PCI (25.6% vs. 17.6%; HR: 1.42, 95% CI: 1.18-1.70). The increased rate of MACE was driven mainly by MI (HR 1.67, 95% CI: 1.20-2.31) but not death (HR 0.99, 95% CI: 0.72-1.35). Conclusions: In routine practice, we found 1 in 4 patients did not receive PCI for ischemic lesions while 1 in 8 received PCI for non-ischemic lesions. Performing PCI procedures according to recommended FFR cutoffs was associated with lower rates of clinical events.

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P6186Symptomatic effect of coronary revascularization at 1-year follow-up in stable chest pain - prediction by coronary computed tomography angiography derived fractional flow reserve

European Heart Journal ◽

10.1093/eurheartj/ehz746.0792 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

K T Madsen ◽

B L Noergaard ◽

K T Veien ◽

P Larsen ◽

M Husain ◽

...

Keyword(s):

Chest Pain ◽

Fractional Flow Reserve ◽

Coronary Revascularization ◽

Symptomatic Relief ◽

Fractional Flow ◽

Coronary Cta ◽

Coronary Ct ◽

Flow Reserve ◽

Stable Chest Pain

Abstract Introduction Coronary CT angiography (CTA) derived fractional flow reserve (FFRct) is increasingly being used for guiding referral to invasive procedures in patients with stable chest pain. However, the ability of FFRct to predict the symptomatic effect of revascularization remains unclear. Purpose To evaluate the ability of different vessel-specific physiological FFRct derived measures of ischemia for predicting the occurrence of chest pain one year after coronary revascularization in stable patients. Methods Retrospective study in patients with stable chest pain referred for coronary angiography based on coronary CTA. Standard acquired coronary CTA data sets were transmitted for core-laboratory analysis at HeartFlow. Patients were categorized as positive for ischemia using 3 different algorithms: Lowest in vessel FFRct-value ≤0.80; ΔFFRct ≥0.06 or a combination of the two. Personnel responsible for downstream patient management had no information on FFRct test results. Classification of revascularization was performed based on the applied FFRct algorithm: complete if all FFRct positive lesions were revascularized; incomplete if ≥1 FFRct positive lesion was not revascularized. Symptomatic status at 1-year follow-up was obtained by a visit in the outpatient clinic or by telephone. Results A total of 172 patients were included. Revascularization was performed in 62 (35%) patients. At 1-year follow-up 48 (28%) patients had chest pain; 15 (24%) revascularized vs 33 (30%) non-vascularized patients, p=0.415. No difference in utilization of anti-anginal medicine for patients with and without chest pain was registered at 1-year follow-up. The association between the chosen FFRct algorithm, revascularization and occurrence of chest pain at 1-year follow-up are shown in the Table. FFRct, Revascularization and Chest pain FFRCT, Algorithm Revascularizationb Patients with chest pain 1-year risk of chest pain p-valuec N (%) OR (95%-CI) Distal FFRCT ≤0.80 Incomplete 32 (34) Ref. Distal FFRCT ≤0.80 Complete 4 (15) 0.34 (0.11, 1.06) Distal FFRCT >0.80 No 11 (24) 0.61 (0.27, 1.35) 0.097 ΔFFRCT ≥0.06 Incomplete 34 (35) Ref. ΔFFRCT ≥0.06 Complete 7 (21) 0.49 (0.19, 1.24) ΔFFRCT <0.06 No 7 (18) 0.41 (0.16, 1.03) 0.074 Combinationa abnormal Incomplete 30 (40) Ref. Combination abnormal Complete 6 (18) 0.32 (0.12, 0.87) Combination normal No 11 (19) 0.35 (0.16, 0.78) 0.009 aDistal FFRCT ≤0.80 and ΔFFRCT ≥0.06. bIncomplete (≥1 FFRCT positive lesion not revascularized); complete (All FFRCT positive lesions revascularized); No (No FFRCT positive lesions and revascularization not performed). cBetween group comparison performed using logistic regression. Conclusion Revascularization based on classification by FFRct is associated with symptomatic relief at 1-year follow-up in patients with stable chest pain.

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