Prognostic Implications of Fractional Flow Reserve After Coronary Stenting

Hwang, Doyeon; Koo, Bon‐Kwon; Zhang, Jinlong; Park, Jiesuck; Yang, Seokhun; Kim, Minsang; Yun, Jun Pil; Lee, Joo Myung; Nam, Chang‐Wook; Shin, Eun‐Seok; Doh, Joon‐Hyung; Chen, Shao‐Liang; Kakuta, Tsunekazu; Tóth, Gábor G.; Piróth, Zsolt; Johnson, Nils P.; Pijls, Nico H.J.; Hakeem, Abdul; Uretsky, Barry F.; Hokama, Yohei; Tanaka, Nobuhiro; Lim, Hong–Seok; Ito, Tsuyoshi; Matsuo, Akiko; Azzalini, Lorenzo; Leesar, Massoud A.; Neleman, Tara; Mieghem, Nicolás M. Van; Diletti, Roberto; Daemen, Joost; Collison, Damien; Collet, Carlos; Bruyne, Bernard De

doi:10.1001/jamanetworkopen.2022.32842

Cited by 48 publications

(42 citation statements)

References 64 publications

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“…Although clinical outcomes between IVUS and FFR groups were not significantly different according to the prespecified optimization criteria in this study, high-risk revascularized vessels can be defined using the optimal cutoff of post-PCI FFR, MSA, and plaque burden at stent edge, which were associated with a higher risk of TVF than low-risk revascularized vessels. This finding aligns with prior publications that reported the prognostic value of residual ischemia, or IVUS-defined post-PCI plaque burden or stent underexpansion . It should be noted that there was no statistically significant association of continuous FFR and IVUS parameters with TVF did in this study.…”

Section: Discussionsupporting

confidence: 92%

“…While intravascular imaging is recommended for planning and optimization of PCI, poststent physiological assessment can also independently estimate risk of adverse clinical events after stent implantation . Nonetheless, head-to-head comparison of clinical outcomes between physiology- and imaging-based PCI optimization has rarely been conducted.…”

Section: Discussionmentioning

confidence: 99%

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Physiology- or Imaging-Guided Strategies for Intermediate Coronary Stenosis

Yang,

Kang,

Hwang

et al. 2024

JAMA Netw Open

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ImportanceTreatment strategies for intermediate coronary lesions guided by fractional flow reserve (FFR) and intravascular ultrasonography (IVUS) have shown comparable outcomes. Identifying low-risk deferred vessels to ensure the safe deferral of percutaneous coronary intervention (PCI) and high-risk revascularized vessels that necessitate thorough follow-up can help determine optimal treatment strategies.ObjectivesTo investigate outcomes according to treatment types and FFR and IVUS parameters after FFR- or IVUS-guided treatment.Design, Setting, and ParticipantsThis cohort study included patients with intermediate coronary stenosis from the Fractional Flow Reserve and Intravascular Ultrasound-Guided Intervention Strategy for Clinical Outcomes in Patients With Intermediate Stenosis (FLAVOUR) trial, an investigator-initiated, prospective, open-label, multicenter randomized clinical trial that assigned patients into an IVUS-guided strategy (which recommended PCI for minimum lumen area [MLA] ≤3 mm2 or 3 mm2 to 4 mm2 with plaque burden [PB] ≥70%) or an FFR-guided strategy (which recommended PCI for FFR ≤0.80). Data were analyzed from November to December 2022.ExposuresFFR or IVUS parameters within the deferred and revascularized vessels.Main Outcomes and MeasuresThe primary outcome was target vessel failure (TVF), a composite of cardiac death, target vessel myocardial infarction, and revascularization at 2 years.ResultsA total of 1619 patients (mean [SD] age, 65.1 [9.6] years; 1137 [70.2%] male) with 1753 vessels were included in analysis. In 950 vessels for which revascularization was deferred, incidence of TVF was comparable between IVUS and FFR groups (3.8% vs 4.1%; P = .72). Vessels with FFR greater than 0.92 in the FFR group and MLA greater than 4.5 mm2 or PB of 58% or less in the IVUS group were identified as low-risk deferred vessels, with a decreased risk of TVF (hazard ratio [HR], 0.25 [95% CI, 0.09-0.71]; P = .009). In 803 revascularized vessels, the incidence of TVF was comparable between IVUS and FFR groups (3.6% vs 3.7%; P = .95), which was similar in the revascularized vessels undergoing PCI optimization (4.2% vs 2.5%; P = .31). Vessels with post-PCI FFR of 0.80 or less in the FFR group or minimum stent area of 6.0 mm2 or less or with PB at stent edge greater than 58% in the IVUS group had an increased risk for TVF (HR, 7.20 [95% CI, 3.20-16.21]; P &lt; .001).Conclusions and RelevanceIn this cohort study of patients with intermediate coronary stenosis, FFR- and IVUS-guided strategies showed comparable outcomes in both deferred and revascularized vessels. Binary FFR and IVUS parameters could further define low-risk deferred vessels and high-risk revascularized vessels.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 99%

Physiology- or Imaging-Guided Strategies for Intermediate Coronary Stenosis

Yang,

Kang,

Hwang

et al. 2024

JAMA Netw Open

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“…In addition, it was found that FFR values measured after PCI could predict the long-term outcome of patients [25]. Systematic reviews and metaanalysis had also reached similar conclusions [10,26]. In recent years, studies had shown that QFR could also predict post-PCI VOCE [1,[12][13][14][15][16].…”

Section: Discussionmentioning

confidence: 83%

“…Tis method should be feasible. Tis is also the case with other metaanalysis, such as the meta-analysis published by Hwang [26] in JAMA in 2022. Hence, the results of this study should be considered exploratory.…”

Section: Limitationsmentioning

confidence: 84%

Predictive Value of Post-Percutaneous Coronary Intervention Quantitative Flow Ratio for Vessel-Oriented Composite Endpoint

Liu,

Cai,

Zheng

et al. 2023

Journal of Interventional Cardiology

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At present, there is a lack of indicators, which can accurately predict the post-percutaneous coronary intervention (post-PCI) vessel-oriented composite endpoint (VOCE). Recent studies showed that the post-PCI quantitative flow ratio (QFR) can predict post-PCI VOCE. PubMed, Embase, and Cochrane were searched from inception to March 27, 2022, and the cohort studies about that the post-PCI QFR predicts post-PCI VOCE were screened. Meta-analysis was performed, including 6 studies involving 4518 target vessels. The results of the studies included in this meta-analysis all showed that low post-PCI QFR was an independent risk factor for post-PCI VOCE after adjusting for other factors, HR (95% CI) ranging from 2.718 (1.347–5.486) to 6.53 (2.70–15.8). Our meta-analysis showed that the risk of post-PCI VOCE was significantly higher in the lower post-PCI QFR group than in the higher post-PCI QFR group (HR: 4.14, 95% CI: 3.00–5.70, P < 0.001, I2 = 27.9%). Post-PCI QFR has a good predictive value for post-PCI VOCE. Trial Registration. This trial is registered with CRD42022322001.

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“…23 This is based on the fact that not all PCIs were necessarily physiologically optimized, despite physiology-guided and angiographically successful PCI, and that clinical outcomes differed significantly according to post-PCI physiological optimization. 24 Meanwhile, there has been an attempt to use IVUS as a treatment decision-making tool. In a previous study by Nam et al, IVUS-guided treatment decision-making resulted in higher rates of revascularization than FFR-guided treatment decision-making in 167 patients with intermediate coronary artery stenosis; however, there was no significant difference in major adverse cardiac event rates between the 2 groups at 1 year.…”

Section: Discussionmentioning

confidence: 99%

Clinical Outcomes of Deferred Lesions by IVUS Versus FFR-Guided Treatment Decision

Lee,

Kim,

Hong

et al. 2023

Circ: Cardiovascular Interventions

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BACKGROUND: There are limited data regarding the safety of deferral of percutaneous coronary intervention based on intravascular ultrasound (IVUS) findings. The current study sought to compare the prognosis between deferred lesions based on IVUS and fractional flow reserve (FFR)–guided treatment decision. METHODS: This study is a post hoc analysis of the FLAVOUR randomized trial (Fractional Flow Reserve and Intravascular Ultrasound for Clinical Outcomes in Patients With Intermediate Stenosis) that compared 2-year clinical outcomes between IVUS- and FFR-guided treatment decision on intermediate coronary artery lesions using predefined criteria. In both IVUS and FFR groups, vessels were classified into deferred or revascularized vessels, and patients were classified as those with or without deferred lesions. Vessel-oriented composite outcomes (cardiac death, target vessel myocardial infarction, or target vessel revascularization) in deferred vessels and patient-oriented composite outcomes (death, myocardial infarction, or any revascularization) in patients with deferred lesions were compared between the IVUS and FFR groups. RESULTS: A total of 1682 patients and 1820 vessels were analyzed, of which 922 patients and 989 vessels were deferred. At 2 years, there was no difference in the cumulative incidence of vessel-oriented composite outcomes in deferred vessels between IVUS (n=375) and FFR (n=614) groups (3.8% versus 4.1%; hazard ratio, 0.91 [95% CI, 0.47–1.75]; P =0.77). The risk of vessel-oriented composite outcomes was comparable between deferred and revascularized vessels following treatment decision by IVUS (3.8% versus 3.5%; hazard ratio, 1.09 [95% CI, 0.54–2.19]; P =0.81) and FFR (4.1% versus 3.6%; hazard ratio, 1.14 [95% CI, 0.56–2.32]; P =0.72). In comparison of patient-oriented composite outcomes in patients with deferred lesions, there was no significant difference between the IVUS (n=357) and FFR (n=565) groups (6.2% versus 5.9%; hazard ratio, 1.05 [95% CI, 0.61–1.80]; P =0.86). CONCLUSIONS: In patients with intermediate coronary artery stenosis, deferral of percutaneous coronary intervention based on IVUS-guided treatment decision showed comparable risk of clinical events with FFR-guided treatment decision. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02673424.

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Prognostic Implications of Fractional Flow Reserve After Coronary Stenting

Cited by 48 publications

References 64 publications

Physiology- or Imaging-Guided Strategies for Intermediate Coronary Stenosis

Physiology- or Imaging-Guided Strategies for Intermediate Coronary Stenosis

Predictive Value of Post-Percutaneous Coronary Intervention Quantitative Flow Ratio for Vessel-Oriented Composite Endpoint

Clinical Outcomes of Deferred Lesions by IVUS Versus FFR-Guided Treatment Decision

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