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

Courtis, Javier; Rodés‐Cabau, Josep; Larose, Éric; Déry, Jean‐Pierre; Nguyen, Can M.; Proulx, Guy; Gleeton, Onil; Roy, Louis; Barbeau, Gérald; Noël, Bernard; DeLarochellière, Robert; Bertrand, Olivier

doi:10.1002/ccd.21406

Cited by 47 publications

(40 citation statements)

References 21 publications

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“…Our findings differ from those in the study by Courtis et al, 23 who observed in 107 patients that deferral of revascularization in patients who had moderate coronary lesions and FFR measurements in the borderline range between 0.75 and 0.80 was associated with a higher rate of cardiac events after 1 year. These were largely attributed to a significantly higher rate of coronary revascularizations in the target vessel due to the persistence or increase in angina symptoms.…”

Section: Discussioncontrasting

confidence: 99%

“…We conclude from our study as well as from the data of Courtis et al 23 and Lavi et al, 26 that patients with borderline FFR measurement values may be deferred from revascularization without putting them at an increased risk for ''hard'' events, such as MI and cardiac death. It therefore seems reasonable to recommend medical treatment and continued surveillance for the majority of these patients as a first line therapy.…”

Section: Discussionsupporting

confidence: 65%

“…The short-term, as well as long-term efficacy and safety of deferring revascularization when FFR is ≥0.75 has also been documented by several trials. 3,15,16,22 However, as Courtis et al 23 rightfully note, only a minority of these studies exhibited FFR values in the gray-zone range and reported mean FFR values of >0.85. Some investigators reported on individual patients who had detectable ischemia above the FFR cut-off of 0.75.…”

Section: Discussionmentioning

confidence: 99%

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Clinical Outcome Following Conservative vs Revascularization Therapy in Patients With Stable Coronary Artery Disease and Borderline Fractional Flow Reserve Measurements

Lindstaedt¹,

Halilcavusogullari²,

Yazar³

et al. 2010

Clinical Cardiology

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Background: Fractional flow reserve (FFR) measurements in the so-called gray-zone range of 0.75 and 0.80 are associated with uncertainty concerning the guidance of patient therapy. It is unclear whether any difference in clinical outcome exists when revascularization treatment of FFR-evaluated lesions in this borderline range is deferred or performed. The objective of this study is to compare the clinical outcome of these patients with respect to their recommended treatment strategy. Methods: Out of a single center database of 900 consecutive patients with stable coronary artery disease, 97 patients with borderline FFR measurements were identified and included in the study. The rate of major adverse cardiac events (MACE; cardiac death, myocardial infarction (MI), coronary revascularization) and the presence of angina were evaluated at follow-up. Results: A total of 48 patients were deferred from revascularization and 49 patients underwent revascularization. There was no difference in risk profile between these groups. At a mean follow-up of 24 ± 16 months, event-free survival in the deferred group was significantly better regarding overall MACE, combined rate of cardiac death, and MI, as well as MACE related to the FFR-evaluated vessel. No difference with regard to the presence of angina was observed. Conclusions: Patients with coronary lesions in the borderline FFR range can be deferred from revascularization without putting them at increased risk for major adverse events. Revascularization may be considered in the course of therapy on an individual basis if typical angina persists or worsens despite maximal medical treatment.

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Section: Discussioncontrasting

confidence: 99%

Section: Discussionsupporting

confidence: 65%

Section: Discussionmentioning

confidence: 99%

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Clinical Outcome Following Conservative vs Revascularization Therapy in Patients With Stable Coronary Artery Disease and Borderline Fractional Flow Reserve Measurements

Lindstaedt¹,

Halilcavusogullari²,

Yazar³

et al. 2010

Clinical Cardiology

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“…When precatheterization stress testing is not available or is thought to underestimate the severity of coronary disease, physiologic testing with FFR may be helpful. An FFR of <0.75 correlates well with ischemia on stress testing [40,42,[47][48][49][50]. For patients with an FFR between 0.75 and 0.80, angina at follow-up was less prevalent in those who underwent PCI compared with those treated conservatively [50].…”

Section: Methods Of Determining Significance Of Coronary Diseasementioning

confidence: 99%

“…An FFR of <0.75 correlates well with ischemia on stress testing [40,42,[47][48][49][50]. For patients with an FFR between 0.75 and 0.80, angina at follow-up was less prevalent in those who underwent PCI compared with those treated conservatively [50]. An FFR of >0.75 or >0.80 correlates with excellent long-term outcomes if PCI is deferred [40,43,[51][52][53].…”

Section: Methods Of Determining Significance Of Coronary Diseasementioning

confidence: 99%

Staging of multivessel percutaneous coronary interventions: An expert consensus statement from the Society for Cardiovascular Angiography and Interventions

Blankenship

Moussa

Chambers

et al. 2011

Cathet Cardio Intervent

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Percutaneous coronary interventions (PCIs) to treat multivessel coronary artery disease (MVCAD) may involve single-vessel or multivessel interventions, performed in one or more stages. This consensus statement reviews factors that may influence choice of strategy and includes six recommendations to guide decisions regarding staging of PCI [1]. Every patient who undergoes PCI should receive optimal therapy for coronary disease, ideally before starting the procedure [2]. Multivessel PCI at the time of diagnostic catheterization should be considered only if informed consent included the risks and benefits of multivessel PCI and the risks and benefits of alternative treatments [3]. When considering multivessel PCI, the interventionist should develop a strategy regarding which stenoses to treat or evaluate, and their order, method, and timing. This strategy should maximize patient benefits, minimize patient risk, and consider the factors described in this article [4]. For planned multivessel PCI, additional vessel(s) should be treated only if the first vessel is treated successfully and if anticipated contrast and radiation doses and patient and operator conditions are favorable [5]. After the first stage of the planned multistage PCI, the need for subsequent PCI should be reviewed before it is performed [6]. Third party payers and quality auditors should recognize that multistage PCI for MVCAD is neither an indication of poor quality nor an attempt to increase reimbursement when performed according to recommendations in this article.V C 2011 Wiley Periodicals, Inc.

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Should we revascularize patients with moderate coronary lesions and borderline fractional flow reserve measurements?

Zijlstra

2008

Cathet Cardio Intervent

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Since its introduction in the nineties, the measurement of fractional flow reserve (FFR) to assess the functional severity of coronary artery stenoses has become an indispensable and practical tool for clinical decision making in the catheterization laboratory [1,2]. A FFR value of <0.75 is a generally accepted indication for a revascularization procedure, and several trials have documented the short-as well as long-term efficacy and safety of deferring revascularization when the FFR is 0.75.However, two important caveats of this method should be kept in mind when we take management decision for individual patients. Firstly FFR measurements are a reliable reflection of the functional severity of a stable coronary artery lesion, but this technique does not predict the future likelihood of disease progression or plaque rupture and its consequences [3]. Nevertheless, the clinical data document an excellent and remarkably good predictive value with regard to major adverse cardiac events, including infarction and death, even though these events are primarily related to plaque destabilization. Secondly, clinicians will certainly know what to do when the FFR is <0.75 or >0.80, but how to proceed with ''borderline'' FFR measurements (0.75-0.80)? Of course it is an option to postpone a final decision until additional noninvasive testing for myocardial ischemia is performed, and such a policy is certainly inline with current PCI guidelines [2].In this issue of Catheterization and Cardiovascular Interventions Courtis et al. [4] provide important new data on how to manage patients with moderate coronary lesions and borderline FFR values. From a cohort of 107 patients with at least one moderate cor-onary lesion with a FFR value between 0.75 and 0.80, a revascularization procedure was performed in 63 (59%) patients and 44 (41%) did not undergo revascularization and continued medical treatment. Serious adverse events such as death and myocardial infarction were rare in both groups. During followup, angina was more frequent in the patients with only medical therapy; 23% of these patients needed a revascularization procedure compared to only 5% in the invasive group (P 5 0.005). Although confirmation in a randomized controlled trial would be preferable, it seems reasonable to conclude from these data that, provided the risk of procedural complications is low, patients with moderate or intermediate coronary lesions and borderline FFR measurements should undergo PCI. This approach reduces the prevalence of angina and the need for subsequent procedures, and is therefore both patient-friendly and cost-effective.In clinical practice, the final decision to perform or defer PCI should always be made on an individual basis. Besides procedural complications, the risk of clinical recurrence due to restenosis will also be a prominent consideration. This makes the use of drug-eluting stents an important factor in the balance between an interventional versus a conservative approach in patients with moderate lesions and borderline FFR measurem...

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

Cited by 47 publications

References 21 publications

Clinical Outcome Following Conservative vs Revascularization Therapy in Patients With Stable Coronary Artery Disease and Borderline Fractional Flow Reserve Measurements

Clinical Outcome Following Conservative vs Revascularization Therapy in Patients With Stable Coronary Artery Disease and Borderline Fractional Flow Reserve Measurements

Staging of multivessel percutaneous coronary interventions: An expert consensus statement from the Society for Cardiovascular Angiography and Interventions

Should we revascularize patients with moderate coronary lesions and borderline fractional flow reserve measurements?

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