Association Between Adherence to Fractional Flow Reserve Treatment Thresholds and Major Adverse Cardiac Events in Patients With Coronary Artery Disease

Abstract

IMPORTANCE Fractional flow reserve (FFR) is an invasive measurement used to assess the potential of a coronary stenosis to induce myocardial ischemia and guide decisions for percutaneous coronary intervention (PCI). It is not known whether established FFR thresholds for PCI are adhered to in routine interventional practice and whether adherence to these thresholds is associated with better clinical outcomes.OBJECTIVE To assess the adherence to evidence-based FFR thresholds for PCI and its association with clinical outcomes. DESIGN, SETTING, AND PARTICIPANTSA retrospective, multicenter, population-based cohort study of adults with coronary artery disease undergoing single-vessel FFR assessment (excluding ST-segment elevation myocardial infarction) from April 1, 2013, to March 31, 2018, in Ontario, Canada, and followed up until March 31, 2019, was conducted. Two separate cohorts were created based on FFR thresholds (Յ0.80 as ischemic and >0.80 as nonischemic). Inverse probability of treatment weighting was used to account for treatment selection bias.EXPOSURES PCI vs no PCI. MAIN OUTCOMES AND MEASURESThe primary outcome was major adverse cardiac events (MACE) defined by death, myocardial infarction, unstable angina, or urgent coronary revascularization.RESULTS There were 9106 patients (mean [SD] age, 65 [10.6] years; 35.3% female) who underwent single-vessel FFR measurement. Among 2693 patients with an ischemic FFR, 75.3% received PCI and 24.7% were treated only with medical therapy. In the ischemic FFR cohort, PCI was associated with a significantly lower rate and hazard of MACE at 5 years compared with no PCI (31.5% vs 39.1%; hazard ratio, 0.77 [95% CI, 0.63-0.94]). Among 6413 patients with a nonischemic FFR, 12.6% received PCI and 87.4% were treated with medical therapy only. PCI was associated with a significantly higher rate and hazard of MACE at 5 years compared with no PCI (33.3% vs 24.4%; HR, 1.37 [95% CI, 1.14-1.65]) in this cohort.CONCLUSIONS AND RELEVANCE Among patients with coronary artery disease who underwent single-vessel FFR measurement in routine clinical practice, performing PCI, compared with not performing PCI, was significantly associated with a lower rate of MACE for ischemic lesions and a higher rate of MACE for nonischemic lesions. These findings support the performance of PCI procedures according to evidence-based FFR thresholds.

Agreement Between Invasive Wire-Based and Angiography-Based Vessel Fractional Flow Reserve Assessment on Intermediate Coronary Stenoses

“…Performing PCI procedures in accordance to FFR recommendations was associated with better clinical outcomes ( 3 ).…”

JCS 2022 Guideline Focused Update on Diagnosis and Treatment in Patients With Stable Coronary Artery Disease

“…As stated, improvement in clinical outcomes after revascularization for stable CAD patients (compared with OMT) has not been clearly shown, even in patients with severe myocardial ischemia. Coronary revascularization for lesions without evidence of ischemia does not improve cardiovascular outcomes and may even worsen the patient's condition, 107 Therefore, it is important to identify patients who may benefit from revascularization through assessment of patient-reported outcomes and non-invasive imaging, as addressed in the previous chapters. 143 However, as the COURAGE trial incorporated a large number of patients without significant myocardial ischemia, the results were diluted.…”

Cardiac Surgery 2021 Reviewed

“…However, since the vast majority of infarct-causing coronary lesions are not flow relevant, 4,6,8 current state of the art PCI 7 is unlikely to address this mechanism in statistically relevant dimensions, because stenting non flow-limiting lesions is discouraged 7 and potentially even harmful. 11 Conservative treatment of CAD has made tremendous progress over the years and is an important part of the treatment of every patient with atherosclerotic coronary lesions. In 2021, a sub-analysis of the SYNTAX-trial demon-strated that patients receiving optimal medical therapy at 5 years illustrated a better survival at 10 years than those who did not receive optimal medical therapy.…”