Economic evaluation of fractional flow reserve-guided versus angiography-guided multivessel revascularisation in ST-segment elevation myocardial infarction patients in the FLOWER-MI randomised trial

Bras, Alicia Le; Puymirat, Étienne; Rabetrano, Hasina; Cayla, Guillaume; Simon, Tabassome; Steg, Gabriel; Montalescot, Gilles; Varenne, Olivier; Bonello, Laurent; Coste, Pierre; Delarche, Nicolas; Chassaing, Stéphan; Letocart, Vincent; Châtellier, Gilles; Danchin, Nicolás; Durand‐Zaleski, Isabelle

doi:10.4244/eij-d-21-00867

Cited by 6 publications

(3 citation statements)

References 15 publications

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“…One analysis used actual individual patient data from the FRAME-AMI trial, and the other was based on the Markov model using previously published evidence. 12,14,15,[21][22][23][24][25][26][27][28][29][30][31]…”

Section: Discussionmentioning

confidence: 99%

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Cost-Effectiveness of Fractional Flow Reserve–Guided Treatment for Acute Myocardial Infarction and Multivessel Disease

Hong,

Lee,

Lee

et al. 2024

JAMA Netw Open

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ImportanceComplete revascularization by non–infarct-related artery (IRA) percutaneous coronary intervention (PCI) in patients with acute myocardial infarction is standard practice to improve patient prognosis. However, it is unclear whether a fractional flow reserve (FFR)–guided or angiography-guided treatment strategy for non-IRA PCI would be more cost-effective.ObjectiveTo evaluate the cost-effectiveness of FFR-guided compared with angiography-guided PCI in patients with acute myocardial infarction and multivessel disease.Design, Setting, and ParticipantsIn this prespecified cost-effectiveness analysis of the FRAME-AMI randomized clinical trial, patients were randomly allocated to either FFR-guided or angiography-guided PCI for non-IRA lesions between August 19, 2016, and December 24, 2020. Patients were aged 19 years or older, had ST-segment elevation myocardial infarction (STEMI) or non-STEMI and underwent successful primary or urgent PCI, and had at least 1 non-IRA lesion (diameter stenosis &gt;50% in a major epicardial coronary artery or major side branch with a vessel diameter of ≥2.0 mm). Data analysis was performed on August 27, 2023.InterventionFractional flow reserve–guided vs angiography-guided PCI for non-IRA lesions.Main Outcomes and MeasuresThe model simulated death, myocardial infarction, and repeat revascularization. Future medical costs and benefits were discounted by 4.5% per year. The main outcomes were quality-adjusted life-years (QALYs), direct medical costs, incremental cost-effectiveness ratio (ICER), and incremental net monetary benefit (INB) of FFR-guided PCI compared with angiography-guided PCI. State-transition Markov models were applied to the Korean, US, and European health care systems using medical cost (presented in US dollars), utilities data, and transition probabilities from meta-analysis of previous trials.ResultsThe FRAME-AMI trial randomized 562 patients, with a mean (SD) age of 63.3 (11.4) years. Most patients were men (474 [84.3%]). Fractional flow reserve–guided PCI increased QALYs by 0.06 compared with angiography-guided PCI. The total cumulative cost per patient was estimated as $1208 less for FFR-guided compared with angiography-guided PCI. The ICER was −$19 484 and the INB was $3378, indicating that FFR-guided PCI was more cost-effective for patients with acute myocardial infarction and multivessel disease. Probabilistic sensitivity analysis showed consistent results and the likelihood iteration of cost-effectiveness in FFR-guided PCI was 97%. When transition probabilities from the pairwise meta-analysis of the FLOWER-MI and FRAME-AMI trials were used, FFR-guided PCI was more cost-effective than angiography-guided PCI in the Korean, US, and European health care systems, with an INB of $3910, $8557, and $2210, respectively. In probabilistic sensitivity analysis, the likelihood iteration of cost-effectiveness with FFR-guided PCI was 85%, 82%, and 31% for the Korean, US, and European health care systems, respectively.Conclusions and RelevanceThis cost-effectiveness analysis suggests that FFR-guided PCI for non-IRA lesions saved medical costs and increased quality of life better than angiography-guided PCI for patients with acute myocardial infarction and multivessel disease. Fractional flow reserve–guided PCI should be considered in determining the treatment strategy for non-IRA stenoses in these patients.Trial RegistrationClinicalTrials.gov Identifier: NCT02715518

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Section: Discussionmentioning

confidence: 99%

“…Statistical analysis was planned in 2 ways. One analysis used actual individual patient data from the FRAME-AMI trial, and the other was based on the Markov model using previously published evidence …”

Section: Methodsmentioning

confidence: 99%

Cost-Effectiveness of Fractional Flow Reserve–Guided Treatment for Acute Myocardial Infarction and Multivessel Disease

Hong,

Lee,

Lee

et al. 2024

JAMA Netw Open

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“…For these reasons, completeness of revascularization guided by coronary physiology in ACS patients has been attempted. However, the recent FLOWER-MI (Flow Evaluation to Guide Revascularization in Multi-Vessel ST-Elevation Myocardial Infarction) trial showed that FFR-guided PCI was not superior on both clinical and economic endpoints compared to angiography-guided PCI in STEMI, although the statistical power was inadequate and follow-up limited to a 1-year duration ( 21 , 49 ). Whether benefits can be achieved using physiological approaches among ACS patients remains controversial.…”

Section: Prognostic Implications Of Qfr In Acsmentioning

confidence: 99%

Angiographic quantitative flow ratio in acute coronary syndrome: beyond a tool to define ischemia-causing stenosis—a literature review

Chu¹,

Lin²,

Yan³

et al. 2022

Cardiovasc Diagn Ther

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Background and Objective: Numerous studies have demonstrated the safety and effectiveness of physiology-guided coronary revascularization in chronic coronary syndrome, resulting in a high level of guideline recommendation for these patients. However, the application of coronary physiology in acute coronary syndrome (ACS), especially in the acute phase of myocardial infarction, remains challenging. Over the last decade, the number of novel physiological indices derived from the computation of angiography have been developed as alternatives to pressure wire-based fractional flow reserve. Among these angiography-based indices, the quantitative flow ratio (QFR) is undoubtedly the one with the largest amount of data cumulated so far. In this article, we aim to review the related studies that describe efforts to investigate the diagnostic role of QFR and discuss perspectives for its current and future applications in the setting of the ACS.Methods: A literature search was performed on the electronic databases, including PubMed, Google Scholar and Web of Science covering publications in English up to May 2022.

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Quantitative flow ratio-guided staged percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction

Hou,

Zhu,

Zhao

et al. 2024

Heliyon

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Economic evaluation of fractional flow reserve-guided versus angiography-guided multivessel revascularisation in ST-segment elevation myocardial infarction patients in the FLOWER-MI randomised trial

Cited by 6 publications

References 15 publications

Cost-Effectiveness of Fractional Flow Reserve–Guided Treatment for Acute Myocardial Infarction and Multivessel Disease

Cost-Effectiveness of Fractional Flow Reserve–Guided Treatment for Acute Myocardial Infarction and Multivessel Disease

Angiographic quantitative flow ratio in acute coronary syndrome: beyond a tool to define ischemia-causing stenosis—a literature review

Quantitative flow ratio-guided staged percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction

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