Network meta‐analysis comparing iFR versus FFR versus coronary angiography to drive coronary revascularization

Abstract

Aims Instantaneous free‐wave ratio (iFR) has been recently demonstrated non‐inferior to fractional flow reserve (FFR) to drive coronary revascularization; however, no study has compared iFR versus coronary angiography (CA). We performed a network meta‐analysis to evaluate efficacy and safety of iFR‐ versus CA‐guided strategy. Methods and Results We searched for randomized trials and studies with propensity score matching in The Cochrane Collaboration Central Register of Controlled Trials, EMBASE, and MEDLINE/Pubmed. CA, FFR, and iFR were the three competitive arms, MACE (a composite endpoint of death, myocardial infarction [MI], and target vessel revascularization [TVR]) was the primary endpoint, while its single components the secondary ones. Subgroup analysis was performed for patients presenting with stable coronary artery disease. Eight studies were selected: 4126 patients were evaluated with FFR, 2160 with iFR, and 2214 with CA, acute coronary syndrome (ACS) was the most frequent admission diagnosis. After 12 months, rates of MACE and all‐cause death did not differ between groups (respectively OR 1.04 and OR 0.86 for iFR vs FFR). Both FFR and iFR reduced TVR compared to CA (respectively OR 0.68 and OR 0.70). In patients with stable CAD both FFR and iFR reduced risk of subsequent MI compared to CA (respectively OR 0.66 and OR 0.79). Conclusion Compared to CA alone, both FFR and iFR are safe and effective in guiding coronary revascularization at 12 months. In patients with stable CAD, both FFR and iFR‐guided revascularization reduce the risk of subsequent MI at 12 months.

Impact of assessment of fractional flow reserve and instantaneous wave-free ratio on clinical outcomes of percutaneous coronary intervention: a systematic review, meta-analysis and meta-regression analysis

“…показатели MACE и смертности от всех причин не отличались между группами. В то же время у пациентов со стабильной ишемической болезнью сердца (ИБС) как ФРК, так и мРК снижали риск последующего ИМ по сравнению с КАГ [20].…”

The optimal timing for non-culprit percutaneous coronary intervention in patients with multivessel coronary artery disease: A pairwise and network meta-analysis of randomized trials

“…For example, for non-culprit intermediate coronary stenosis (50-70% diameter stenosis), physiological assessments [such as fractional flow reserve (FFR), instantaneous wavefree ratio (iFR)] and intravascular imaging [such as Optical coherence tomography (OCT)] may be required to determine the optimal timing of intervention of non-culprit lesions (40). Some meta-analyses and RCTs have compared FFR-guided vs. coronary angiography-guided complete revascularization on clinical outcomes (41)(42)(43)(44)(45). More research is needed in the future to provide more evidence for optimal timing of revascularization for non-culprit lesions in patients with multivessel coronary artery disease.…”

Computational instantaneous wave‐free ratio (IFR) for patient‐specific coronary artery stenoses using 1D network models

“…Further studies have indicated that iFR and FFR have a similar number of negative cardiovascular events after 1 year 41 and thus is at least on-par with FFR. Several studies have compared iFR and FFR [29][30][31][32][33][34][35][36][37] ; however, only one attempted to explain the cause of the various diagnostic disagreements observed between iFR and FFR. 39 The study concluded that it was actually the FFR that was likely overestimating the severity of the stenosis because of the hyperaemic condition rather than iFR underestimating the stenosis, and for the cases that had a positive FFR but negative iFR, the observed coronary flow characteristics were similar to that seen in angiographically unobstructed vessels, which indicates that iFR may be the more reliable and suitable measure.…”

“…25,26 The iFR procedure also requires a pressure sensitive catheter to be inserted in order to measure the pressure drop across stenotic lesion, but iFR is performed under resting conditions, so it does not require a hyperaemic-inducing drug to be administered. The use of iFR was initially met with significant resistance, particularly by the community who strongly supported the use of conventional FFR 27,28 under maximum hyperaemia, but many studies have shown the viability and potential of iFR in diagnosing functionally significant stenotic lesions, showing similar diagnostic accuracy to conventional FFR [29][30][31][32][33][34][35][36][37] and even showing a better repeatability than conventional FFR 38 and a stronger correlation with the coronary velocity flow reserve. 30 Questions still remain on whether iFR can reliably be used to replace FFR as several studies have shown mismatches in patient categorisation between iFR and the clinically trusted technique of conventional FFR, 32 while the reasons for these disagreements were not fully understood.…”