Fractional flow reserve versus angiography for guidance of PCI in patients with multivessel coronary artery disease (FAME): 5-year follow-up of a randomised controlled trial

Nunen, Lokien X. van; Zimmermann, Frederik M.; Tonino, Pim A.L.; Barbato, Emanuele; Baumbach, Andreas; Engstrøm, Thomas; Klauß, Volker; MacCarthy, Philip; Manoharan, Ganesh; Oldroyd, Keith G.; Lee, Peter N Ver; Veer, Marcel van‘t; Fearon, William F.; Bruyne, Bernard De; Pijls, Nico H.J.

doi:10.1016/s0140-6736(15)00057-4

Cited by 535 publications

(317 citation statements)

References 23 publications

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“…Although evidence has shown favorable clinical outcomes of deferred lesions with high FFR despite angiographically significant stenosis,17, 18, 28, 29 there remains a paucity of evidence evaluating lesions with low FFR despite angiographically insignificant stenosis. Current guidelines do not recommend FFR measurement in stenosis with %DS <40% to 50% 20, 21.…”

Section: Discussionmentioning

confidence: 99%

Clinical Outcomes of Deferred Lesions With Angiographically Insignificant Stenosis But Low Fractional Flow Reserve

Lee

Koo

Shin

et al. 2017

JAHA

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BackgroundData are limited regarding outcomes of deferred lesions in patients with angiographically insignificant stenosis but low fractional flow reserve (FFR). We investigated the natural history of angiographically insignificant stenosis with low FFR among patients who underwent routine 3‐vessel FFR measurement.Methods and ResultsFrom December 2011 to March 2014, 1136 patients with 3298 vessels underwent routine 3‐vessel FFR measurement (3V FFR‐FRIENDS study, ClinicalTrials.gov identifier NCT01621438), and this study analyzed the 2‐year clinical outcomes of 1024 patients with 2124 lesions with angiographically insignificant stenosis (percentage of diameter stenosis <50%), in which revascularization was deferred. All lesions were classified according to FFR values, using a cutoff of 0.80 (high FFR >0.80 versus low FFR ≤0.80). The primary end point was outcome of major adverse cardiovascular events (a composite of cardiac death, myocardial infarction, and ischemia‐driven revascularization) at 2 years. Mean angiographic percentage of diameter stenosis and FFR of total lesions were 32.5±10.3% and 0.91±0.08%, respectively. Among the total lesions with angiographically insignificant stenosis, 8.7% showed low FFR (185 lesions). The incidence of lesions with low FFR was 2.5%, 3.8%, 9.0%, and 15.1% in categories of percentage of diameter stenosis <20%, 20% to 30%, 30% to 40%, and 40% to 50%, respectively. At 2‐year follow‐up, the low‐FFR group showed a significantly higher risk of major adverse cardiovascular events compared with the high FFR group (3.3% versus 1.2%, hazard ratio: 3.371; 95% CI, 1.346–8.442; P=0.009). In multivariable analysis, low FFR was the most powerful independent predictor of future MACE in deferred lesions with angiographically insignificant stenosis (adjusted hazard ratio: 2.617; 95% CI, 1.026–6.679; P=0.044).ConclusionsIn deferred angiographically insignificant stenosis, lesions with low FFR showed significantly higher event rates than those with high FFR. FFR was an independent predictor of future major adverse cardiovascular events in lesions with angiographically insignificant stenosis.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT01621438.

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Section: Discussionmentioning

confidence: 99%

Clinical Outcomes of Deferred Lesions With Angiographically Insignificant Stenosis But Low Fractional Flow Reserve

Lee

Koo

Shin

et al. 2017

JAHA

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“…Obstructive CAD occurs when one or more of the coronary arteries which supply blood to myocardium are narrowed owing to plaque buildup on the arteries' inner walls, causing stenosis. Only functionally significant stenoses, i.e stenoses that significantly limit the blood flow to the myocardium and lead to myocardial ischemia need to be treated to reduce CAD morbidity (Pijls et al, 1996;Tonino Email address: m.zreik@umcutrecht.nl (Majd Zreik) et al, Pijls et al, 2010;van Nunen et al, 2015). Conversely, treating stenoses that are not functionally significant leads to more harm than benefit (Pijls et al, 2010(Pijls et al, , 2013.…”

Section: Introductionmentioning

confidence: 99%

Deep learning analysis of the myocardium in coronary CT angiography for identification of patients with functionally significant coronary artery stenosis

Zreik

Leßmann

Hamersvelt

et al. 2018

Medical Image Analysis

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In patients with coronary artery stenoses of intermediate severity, the functional significance needs to be determined. Fractional flow reserve (FFR) measurement, performed during invasive coronary angiography (ICA), is most often used in clinical practice. To reduce the number of ICA procedures, we present a method for automatic identification of patients with functionally significant coronary artery stenoses, employing deep learning analysis of the left ventricle (LV) myocardium in rest coronary CT angiography (CCTA).The study includes consecutively acquired CCTA scans of 166 patients who underwent invasive FFR measurements. To identify patients with a functionally significant coronary artery stenosis, analysis is performed in several stages. First, the LV myocardium is segmented using a multiscale convolutional neural network (CNN). To characterize the segmented LV myocardium, it is subsequently encoded using unsupervised convolutional autoencoder (CAE). As ischemic changes are expected to appear locally, the LV myocardium is divided into a number of spatially connected clusters, and statistics of the encodings are computed as features. Thereafter, patients are classified according to the presence of functionally significant stenosis using an SVM classifier based on the extracted features.Quantitative evaluation of LV myocardium segmentation in 20 images resulted in an average Dice coefficient of 0.91 and an average mean absolute distance between the segmented and reference LV boundaries of 0.7 mm. Twenty CCTA images were used to train the LV myocardium encoder. Classification of patients was evaluated in the remaining 126 CCTA scans in 50 10-fold cross-validation experiments and resulted in an area under the receiver operating characteristic curve of 0.74 ± 0.02. At sensitivity levels 0.60, 0.70 and 0.80, the corresponding specificity was 0.77, 0.71 and 0.59, respectively.The results demonstrate that automatic analysis of the LV myocardium in a single CCTA scan acquired at rest, without assessment of the anatomy of the coronary arteries, can be used to identify patients with functionally significant coronary artery stenosis. This might reduce the number of patients undergoing unnecessary invasive FFR measurements.

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“…6,9,10,[12][13][14] In the unlikely event that this role is downgraded, CT-FFR will suffer accordingly. Of note, the clinical use of CT-FFR is not yet guideline recommended.…”

Section: Reliance On Invasive Ffrmentioning

confidence: 99%

“…12 The FAME trial showed that functional angioplasty, performing PCI on lesions responsible for ischemia, while treating lesions medically that are not hemodynamically significant results in One of the criticisms of the FAME trial was that it did not include a medical therapy arm. Some argued that medical therapy alone would have performed as equally well as FFRguided PCI.…”

mentioning

confidence: 99%

Fractional Flow Reserve and Coronary Computed Tomographic Angiography

Hecht

Narula

Fearon

2016

Circulation Research

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Obstructive coronary artery disease (CAD) produces symptoms and increases the risk of adverse cardiac outcomes. However, determining whether a particular coronary stenosis is responsible for causing myocardial ischemia can be challenging, even with invasive coronary angiography (ICA). how should high-risk plaque be incorporated into treatment decisions? (7) how will CT-FFR influence other functional imaging test utilization, and what will be the effect on the practice of cardiology? (8) will a workstationbased CT-FFR be mandatory? Rapid progress to date suggests that CTA-based lesion-specific ischemia will be the gatekeeper to the cardiac catheterization laboratory and will transform the world of intervention.

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Fractional flow reserve versus angiography for guidance of PCI in patients with multivessel coronary artery disease (FAME): 5-year follow-up of a randomised controlled trial

Cited by 535 publications

References 23 publications

Clinical Outcomes of Deferred Lesions With Angiographically Insignificant Stenosis But Low Fractional Flow Reserve

Clinical Outcomes of Deferred Lesions With Angiographically Insignificant Stenosis But Low Fractional Flow Reserve

Deep learning analysis of the myocardium in coronary CT angiography for identification of patients with functionally significant coronary artery stenosis

Fractional Flow Reserve and Coronary Computed Tomographic Angiography

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